ADRC
Care Transitions
Intervention
Implementation Booklet
California Community Choices
March 2010
i
Table of Contents
Table of Contents ......................................................................................................... ii
Improving Care Transitions: Implementation Overview ........................................ 1
ADRC CTI Work Plan ................................................................................................ 2
Four Pillars ................................................................................................................... 3
Care Transitions Intervention Tools and Forms ...................................................... 4
Sample Transition Coach Visit Sequences and Scripts ........................................... 7
Data Collection Measures ......................................................................................... 16
Project Reports .......................................................................................................... 18
Sample Patient Consent Form .................................................................................. 18
Project Dates .............................................................................................................. 18
Tools and Forms ......................................................................................................... 19
The Personal Health Record .............................................................................. 19
Medication Discrepancy Tool ............................................................................ 27
CTI Coaching Activities & Processes ............................................................... 28
Intervention Activities Checklist ....................................................................... 29
Care Transition Measure-3 (CTM-3) ............................................................... 31
Patient Activation Assessment ........................................................................... 32
Scoring for the Patient Activation Assessment Tool ....................................... 33
Informed Patient Consent - Sample .................................................................. 35
Key Project Dates................................................................................................ 37
ii
Improving Care Transitions: Implementation
Overview
A primary responsibility of the CAL Aging and Disability Resource Connection (ADRC) is to
facilitate and empower individuals to access and use, as appropriate to their needs, aging and
long-term supports. This responsibility will be met, in part, through each ADRCs implementation
of the Care Transitions Intervention (CTI), a low cost, low intensity care transitions model
dedicated to facilitating patient empowerment through skill transfer, building self-efficacy, and
providing transition specific self-care tools.
The CTI, developed by Dr. Eric Coleman and the Care Transitions Program©1www.caretransitions.org, was designed to address potential threats to patient safety during care
transitions by providing patients with the tools and support they need to understand and take a
more active role in managing their health care and care transitions. It was also designed to help
patients avoid repeat hospitalizations and potentially unnecessary institutionalization.
Additionally, the model provides a framework for encouraging larger systems transformations,
including improved clinical practice and cost savings attributable to reductions in hospital
readmission.
The CTI is a low cost, low intensity care transitions
This implementation booklet is
model dedicated to facilitating patient empowerment
intended to assist you (ADRC staff
through skill transfer, building self-efficacy, and
and partners) in the successful
providing transition specific self-care tools.
implementation of the Improving
Care Transitions project at your
site(s). The booklet covers the core components and tools of the Care Transitions Intervention
implementation process:

ADRC CTI Work Plan

Four Pillars

Care Transitions Intervention Tools and Forms

Sample Transition Coach Visit Sequences and Scripts

Data Collection Measures

Project Reports

Sample Patient Consent Form

Project Dates
2/16/162/16/16
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Unless otherwise noted, all materials related to the Care Transitions Intervention are copyright protected: © 2007
Care Transitions Program; Denver, Colorado. All rights reserved.
1
ADRC CTI Work Plan
The CTI Work Plan builds on the initial ADRC Work Plan; it serves as the ADRC’s principal
guiding document throughout CTI implementation period. Each site is required to complete a
brief (2-3 page) narrative work plan draft describing the following project elements. The draft
work plan is due April 1, 2010; the final narrative work plan is due April 15, 2010 (San Diego
to submit draft April 15, 201- final due April 30, 2010). Send work plans to Karol
Swartzlander, KSwartz2@chhs.ca.gov, and Monique Parrish, mparrish@lifecoursestrategies.com.

Identification of team members and team leader.

Selection and training process of the Transition Coaches.

Agreements between sender and receiver partners regarding facilities, patients and
Transition Coaches.

Criteria and process for identifying project patients (referral process); process to describe
the intervention to patients and secure their voluntary participation (consent form); and
mechanism for obtaining, storing and safeguarding patient information.

Plan for addressing medication reconciliation (resolution of discrepancies) – detail
Transition Coach responsibility and team oversight, e.g., a supervisor available to assess
medication questions, urgent or emergency situations.

Project monitoring (e.g., frequency of team meetings, oversight role of team leader, etc.).

Designation of an individual responsible for obtaining, managing, compiling, coding and
transmitting required project data, e.g., to maintain a registry of patients; to collect and
record data; and to send data to Choices staff.

Role and responsibilities of community partners.

Timeline for implementation.
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Four Pillars
The Four Pillars represent the four patient-centered components on which the Coleman Care
Transition Intervention is structured:

Medication Self Management
Focus: Reinforcing the importance of knowing each medication – when, why, and how to
take what is prescribed, and developing an effective medication management system.
Outcome: Patient knows who and what to ask to resolve medication discrepancies or
concerns.

Patient-Centered Health Record (PHR)
Focus: Providing a health care management guide for patients; the PHR is introduced
during the hospital visit and used throughout the program.
Outcome: The patient utilizes the PHR to facilitate communication across providers and
settings. The patient manages his own PHR throughout the program.

Primary Care Provider/Specialist/Pharmacist Follow-Up
Focus: Patient schedules and completes follow up visit (s) with the primary care provider
or specialist as soon as possible after discharge.
Outcome: Patient is prepared to be an active participant in these interactions.

Knowledge of Red Flags
Focus: Enabling the patient to be knowledgeable about indicators that suggest that his or
her condition is worsening and how to respond.
Outcome: Patient is knowledgeable about his or her health condition warning signs and
has a plan to address them.
These areas are addressed through a combination of visits and follow-up calls by the Transition
Coach and the use of several Care Transition tools such as the Personal Health Record and the
Medication Discrepancy Tool. The schedule of visits and follow-up calls represent the “stages”
of the Care Transition Intervention over the four-week intervention period and include the
following:



An initial hospital visit;
One home visit scheduled 24-72 hours post-discharge; and
Three (or several) follow-up phone calls to the patient typically timed around specific
events the coach wants to check up on. For example, calling the patient day-2 postdischarge, to confirm or schedule the home visit, and then a week after the home visit to
inquire about the patient’s follow-up visit with the primary (How did your doctor visit
go?).
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Care Transitions Intervention Tools and Forms
The tools and forms provided in this booklet provide a foundation for the Coleman Care
Transitions Intervention (CTI). The key tools include the Personal Health Record and the
Medication Discrepancy Tool. While all CTI sites are required to use these forms as part of the
intervention, they are not a part of the required data measures for the project (for more detailed
information on each of these forms, see www.caretransitions.org).
The Personal Health Record (PHR) (p. 18) is a critical component of the Care Transitions
Intervention. Its primary purpose is to empower patients to take ownership over important
elements of their medical information and to share this information with the different
practitioners they encounter during care transitions. Key elements of the tool include:
 Patient demographic information; patient medical history;
 A checklist of activities the patient should complete before leaving the care facility;
 Patient medication record;
 Tips on managing health and medications;
 Designated space to write follow-up questions for health care practitioners, as well as the
Transition Coach, and to track follow-up healthcare appointments; and
 The patient’s stated personal health goal -- what he or she hopes to gain as a result of
participating in this program.
Sites should feel free to customize the PHR included with this booklet or adapt a similar tool
used by their organization. The patient and Transition Coach should begin the process of
reviewing and addressing the various components of the PHR, together, during the first visit
(typically in the hospital). Use of the PHR throughout the intervention is instrumental in
encouraging patients to assume control of their health care.
The Medication Discrepancy Tool (MDT) (p. 26) serves as a simple yet powerful patientmedication quality control and review mechanism. The MDT is designed to facilitate
reconciliation of medication regimens across settings and prescribers. Throughout the coaching
process, patients learn about their medications and how to develop a medication monitoring
system that works for them. The MDT is a complementary tool in the coaching process,
allowing both the Transition Coach and the patient to address discrepancies while helping the
patient craft a viable plan for addressing current and future medication discrepancies.
Specifically, the MDT is used during the home visit when the Transition Coach reviews with the
patient his or her medication regimen, evaluating whether the patient has both filled and
understands his or her medications (when, why, and how to take what is prescribed).
Additionally, the MDT allows the Transition Coach to document other key medication issues
such as: whether the patient is confused by pre-and post-hospitalization medication regimens;
differences between brand and generic names for medications; whether the discharge instructions
are clear; and, if the patient has experienced any side effects.
It is not the explicit responsibility of the Transition Coach to intervene clinically should a
discrepancy be identified. Rather, the Transition Coach’s role is to use the opportunity of an
identified discrepancy to model for the patient how to address discrepancies and questions that
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arise with his or her primary health care provider. One or more MDTs can be completed (by the
Transition Coach) on patients – as noted, the primary function of the MDT is to provide a
patient-coach tool to facilitate improved patient mastery in the area of medication selfmanagement. MDTs are completed and remain with Transition Coaches. Sites should consider
creating patient files or records, electronic or hard copy, where the Transition Coach can
maintain these forms as well as other patient notes. As noted, the MDT is not part of the data
collection measures required by the Community Choices project.
The CTI Coaching Activities and Processes table (p. 27) provides Transition Coaches with a
guide for implementing various activities by pillar and stage of intervention. An additional tool,
the Intervention Activities Checklist (p. 28), further details coach activities by stage and pillar.
It is recommended that Transition Coaches actively follow these guides to successfully
implement the intervention.
Transition Coaches have the specialized and critical role of coaching (not doing or teaching)
patients through skill transfer (by modeling behaviors that the
patient can see and hear), building self-efficacy (empowering the
Transition Coaches have the
patient to act on his/her own with confidence), and providing
specialized and critical role of
transition specific self-care tools (written records, forms,
coaching (not doing or
medication management system, managing information, etc.).
teaching) patients.
Effective transition coaches, whether they be nurses, social
workers, EMTs, pharmacy technicians, or former health plan case managers/care managers, must
function in a dedicated transition coach role (ideally performing in the transition coaching role
half- to full-time).
Dealing with Emergent and Urgent Problems
From time to time emergency or urgent situations may present themselves in the context of the
home visit or during the medication review process. Below is a guide for Transition Coaches to
assist them with understanding when they might need to take action and “do” versus “coach:”
Emergency: Emergency situations (medical crises – i.e., patient not breathing, evidence of
abuse, etc.) require that Transition Coaches immediately contact 911, the Police, Adult
Protective Services, etc.
Urgent: Urgent situations (significant medication discrepancies, serious medication side effects,
unresolved health concerns, unresolvable confusion, etc.) require the Transition Coach to
encourage the patient to contact his/her health care provider during the visit. If the patient is not
able to follow through for any reason, the Transition Coach should make the appropriate call(s)
and follow-up with a family member if possible.
Important: The Transition Coach should encourage patients with important health issues/
concerns and/or discrepancies that do not require emergency or urgent attention to contact their
health care provider. The Transition Coach should make plans to follow up with the patient
5
(through the follow-up phone calls) to ascertain that the call(s) were made and action has been
taken.
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Sample Transition Coach Visit Sequences and Scripts
The following sample sequences, scripts, and role-play scripts (© 2008 Care Transitions
Program www.caretransitions.org) for the Transition Coach hospital visit, phone call before the
home visit, and home visit are guides for introducing the CTI and the Transition Coach role.
Sample Hospital Visit Sequence

Introduce yourself (Transition Coach)

Introduce and discuss the Care Transitions Program

Inquire about patient’s interest in participating in the program (obtain consent)

If yes, introduce the PHR

If time is available, review the PHR’s Intervention Activities Checklist, focusing on
patient’s understanding of her medication

If time is available, ask patient for a personal goal
Sample Hospital Scripts
In preparation for your first visits, you may want to review these sample scripts of how to
introduce the intervention at the hospital or nursing home; how to schedule the home visit; and
how to formulate the recap at the end of the home visit. We encourage you to practice, using
your own language.
I’m a Transition Coach and I’m here to help you make a successful move from the hospital to
home.
I’d like to visit you at home to help you review your medications and prepare for your follow up
doctor visit.
This will be a different kind of visit from others you may have had such as with the visiting nurse.
After you are discharged, please call me at (phone) to let me know you are home.
After you get home, I will visit you once.
After this visit, I will call you several times to check on how you are doing and answer any
questions you might have.
If you go to a rehabilitation center/nursing home before going home, I will visit you once you get
back home.
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Other ways to explain the intervention and encourage participation
This is a special program/benefit meant to help people after they are discharged from the
hospital.
This program is designed to make life easier, not be intrusive or time-consuming.
Benefits of participation: Free service; Help to prevent hospital readmission; Resource for
questions after discharge.
This program also includes family and caregivers.
Sample Phone Call Script – Before the Home Visit
As soon as you discover the patient has been discharged, you call them, remind them of the
program, and set up a time for the home visit.
Hi, my name is ____. I am the Transition Coach who met you while you were in the hospital
[SNF/other].
I gave you that [green/blue] book. As I mentioned when we first met, I will be coming to your
home to help you review your medications and get you ready for the follow-up appointment with
your doctor.
I’ll be making this visit and then two more phone calls to see how you’re doing over the next few
weeks.
I’d like to set up a time for the home visit that’s convenient for you and any family members who
help with your care.
What would be a good time for us to meet for a home visit?
It would be helpful if you can take a few minutes before we come to gather up all your
medications, any medication lists you have, and the discharge summary from the hospital.
Great—I’ll see you in [days/time].
Sample Home Visit Sequence

Introduce yourself – establish rapport

Clarify role (difference between CTI and Home Health), purpose and length of program

Ask patient about a personal goal he or she can achieve during the four-week
intervention.
8

Begin with recognizing and respecting patient’s desires and interests – start with where
the patient is – inquire about patient’s medication management system (How do you keep
track of your medicine? Is that system working for you? What medications are you taking
and how are you taking them?).

Patients should list all the medications they are taking in their PHR. That list should be
compared to the post-hospitalization medication list, as well as the pre-hospitalization
medication list to identify discrepancies. Because many coaches were ‘doers’ in their
former roles, it is easy to slip into reconciling the medications for the patient. In this new
role, the coach helps the patient identify the pre- and post- hospital medications, identify
discrepancies and develop questions for clarification with the doctor. It is important that
the patient and not the coach record the medications and the notes in the PHR.

In reconciling medication lists, specifically comparing pre and post-hospitalization lists,
patients should write down what they are taking and then be referred back to their
primary provider to review the medication list and to reconcile any discrepancies. ALL
PATIENTS SHOULD BE REFERRED BACK TO THEIR PRIMARY PROVIDER
OR TREATING SPECIALIST FOR MEDICATION RECONCILIATION!!!

Regarding warning signs, the patient should be encouraged to identify his understanding
of any warning signs associated with his condition and a plan of action to address a
worsening condition. If the patient does not know the warning signs, this too should be
captured in the form of a question for the patient’s primary care provider. As with
medication reconciliation, all patients should be referred back to their primary physician
to review the patient’s understanding of the warning signs a condition is worsening and
how to address it.

Use the PHR and the patient’s goal as a guide to address the medication management,
system, the Red Flags, and the 2-3 follow-up questions the patient has written to ask their
health care provider at the and follow-up medical appointment. Throughout the visit, be
sure to encourage the patient to assume ownership and responsibility for his or her health
management (for example, the patient should be doing most of the talking, the patient
should contact his or health provider, the patient should both hold and write in the PHR).

At the end of the visit, encourage the patient to summarize next steps; the Transition
Coach should also recap and explain to the patient what he or she will address during the
follow-up phone calls.
Case Example of a Home Visit Sequence
New coaches are often unsure about how to structure a home visit. The following example
supports a patient centered agenda.
The Coach arrives at Mr. P’s home and explains her role as coach; the purpose of the home visit;
and the importance of the Personal Health Record (PHR). Right away, the Coach engages Mr. P
in the conversation, by asking about his experiences and his health since coming home.
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(“How have you been since you got home?”)
The answer to this question will determine which pillar you move to first.
The Coach helps Mr. P set a 30-Day Personal Goal and shows him where to record it in his PHR.
(“Can you identify a goal you would like to achieve in the next 30 days?”)
The patient’s goal is used to build rapport and structure the visit. Throughout the home visit, they
will continue a discussion of how Mr. P might reach his goal by using his new skills and
knowledge to manage his care and health.
The Coach talks with Mr. P about his health conditions and has him record important issues in
the PHR. As Mr. P records his conditions in his PHR, the Coach prompts him to explain what
symptoms he experiences and how he knows if his conditions are worsening. The Coach helps
Mr. P understand the “red flag” warning symptoms for each condition and how to seek medical
care before a trip to the hospital becomes necessary.
When Mr. P has other questions about his conditions, the Coach shows him where to record
these questions in his PHR to ask his doctor at the follow-up visit. (By using the PHR in this
way, three of the four pillars have been addressed: use of the PHR, Red flags, Follow up)
Based on the patient’s goal and on his concerns, it is often time to work on medications. Mr. P
gathers his pill bottles, pill minders, medication lists, and discharge instructions. The Coach asks
Mr. P to tell her about each medication, what it is for, and how and when he takes it.
(“Can you show me your medications, what you take and how you take it?”)
They compare the medication bottles and any pre hospital medication lists with the discharge
medication list. The Coach helps Mr. P create a new medication list and identify any
discrepancies and questions to discuss with his doctor. By helping the patient clarify his
questions and sitting with him as he records his new medication list, the coach is teaching him
skills he can use again and again.
The Coach asks Mr. P about his experiences with scheduling doctor visits and interacting with
his doctor.
(“Have you had a chance to schedule a follow-up appointment with your doctor?”)
It’s important for the coach to discuss why a follow-up doctor visit is necessary. (Often a
patient’s PCP will not be aware that the patient has been in the hospital.) The coach and patient
role-play asking questions of the doctor or appointment scheduling desk, and getting replies. The
coach and patient work together to use the patient’s understanding and language to form
questions the patient has for the doctor.
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(For example, “I just got out of the hospital and I’m confused about my medications, especially
the ones for my heart”.)
The coach reminds Mr. P to take his PHR to all appointments and suggests writing down the
doctor’s answers to his questions.
The Coach summarizes the information discussed throughout the home visit and asks Mr P. to
identify what activities he will be doing before her next call. She lets the patient know when to
expect her next phone call.
(“Let’s review the most important things we’ve touched on, including your questions and the
things that need to get done before I call you next. What are the top three questions you’d like to
have answered when you connect with your doctor?”)
Sample Introduction Script at Home Visit
Hi, I’m ___your Transition Coach. I’m here today to help you review your medications and
prepare you for your doctor’s visit.
Would you like to gather all your medications, medications lists and papers from the hospital?
Where would you like to sit?
This will be a different kind of visit from others you may have had, such as with a visiting nurse
or physical therapist. I’m here to help you review your medications; be better prepared to meet
with your doctors and specialists; and help you better understand your health. This is the only
time we will meet in person, but I’ll be calling you a few more times to check up and see how you
are doing.
Do you have that [green] book I gave you in the hospital? Let’s start there…
Sample Role-Play Script at Home Visit Introducing the CTI
Staging in Italics:
 Two actors needed – a female transition coach and an older male patient
Props to portray entry into a home and the home kitchen:








Front door leading into open kitchen
Table and two chairs
Counter or side table with a telephone on it
Napkin holder with paper napkins
Salt and pepper
Butter dish
Pencil
Personal Health Record
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


Several sheets of paper
Walker with basket
6 different sized pill bottles scattered in bathroom, on top of TV and in bedroom
Patient is sitting at the kitchen table drinking coffee. There is a knock at the front door.
Patient gets up slowly from the table and walks unsteadily to the front door with his
walker.
Patient: Who is it?
Coach: It’s Mary Joyce your Transition coach. You may remember me from when I came to visit
you while you were in the hospital. (Patient let’s her inside, but looks like he is not quite sure
who this person is).
Patient: So many people came to see me in the hospital.
Coach: I’m the person who gave you that purple booklet! (Coach shows a copy of the PHR)
Patient: Oh yes, I remember! Do you want to sit at the kitchen table?
Coach: Since you’re up could you gather all of your medications and any paper work you got
from the hospital?
Patient: Sure, but it might take me awhile, with this walker. (Patient goes around the house and
gathers pill bottles from the bathroom, bedroom and from on top of the TV. He joins the Coach
sitting at the kitchen table and unloads the pill bottles onto the table, next to a stack of papers.
Coach adjusts her chair so she is sitting 45-90 degrees from the patient. If she sits right next to
the patient, they will not be able to see each other as well, and important nonverbal cues could be
missed. It’s also important that the coach and patient sit at a surface, which makes writing and
handling the bottles and papers more convenient.)
Coach: Well, Mr. Dawson, it’s great to see you today! This is going to be a different kind of
visit from others you’ve had such as the visiting nurse or physical therapist. I’m going to help
you be better prepared to take care of your health conditions with the goal of trying to keep you
from having to go back to the hospital. Together we will review your medications; prepare for
your next doctor’s visit; and help you understand your health condition a bit better.
Just as important as helping you stay well and not need to go back to the hospital is for me to
understand what your goal is for your health. Do you have a goal for your health that you would
like to accomplish over the next 30 days?
Patient: I enjoy attending my granddaughter’s soccer games but I have not felt up to it over the
past two weeks. My goal would be to feel strong enough to be able to go to her soccer games
and sit in the bleachers to watch her play.
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Coach: I believe that together we can help you feel strong enough to make it those soccer
games. We can talk more this during our visit and make a plan for how we can accomplish your
goal.
Patient: That sounds great. How often will I see you?
Coach: This is the only time we will meet in person, but I’ll be calling you at least two more
times to check up and see how you are doing.
Patient: OK. I’m glad you are here. I am a little concerned about some of my pills.
Coach: I want to hear what concerns you have about your pills, so let’s get started. Do you have
that purple Personal Health Record I gave you in the hospital?
Patient: I think it’s in this pile of papers from the hospital – here it is… (tries to hand it to the
coach).
Coach: Actually, this is your record. Why don’t you open it up and take a look.
Sample Role-Play Script at Home Visit Addressing the Personal Goal
Staging in Italics:
 Two actors needed – a female transition coach and an older male patient
Props to portray a home kitchen table:
 Table and two chairs
 Counter or side table with a telephone on it
 Coffee cups – 2
 Napkin holder with paper napkins
 Salt and pepper
 Butter dish
 Pencil
 Personal Health Record
 Medicine bottles on the table
 Several sheets of paper
 Walker
 Cat? :)
Coach and patient are sitting at the kitchen table
Coach: I see you have the Personal Health Record that we went over in the hospital. (Coach
points to the Personal Health Record in a pile of papers). Let’s take a look at that. (Patient pulls
the Personal Health Record out of the pile) Great-thanks (Coach leans towards patient and says)
the first thing I’d like to ask you is: do you have a goal related to your health that you would like
to achieve in the next 30 days?
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Patient: Well, yes! I want to make sure I don’t fall again and break something else. That pain
medicine makes me feel foggy.
Coach: (Nodding her head as she listens to the patient). That’s a great goal. How did your first
fall happen?
Patient: (Looking embarrassed). I fell in the shower. My daughter had been nagging me to put a
grab bar in the shower. But I just hadn’t gotten around to it. I’m having one installed tomorrow-before my daughter visits on Friday! But I worry about the effect these pain pills are having on
me. I think I could fall again even with that grab bar. I just don’t feel right. It’s even a little
hard to walk with my walker now and that wasn’t a problem before.
Coach: So it sounds like one of the things that needs to happen for you to reach your goal is for
you to feel more clear-headed and steady. Did I get that right?
Patient: (Nodding while the coach talks) yes…
Coach: So your goal over the next month is to feel clear headed; and steadier in the shower and
walking with your walker?
Patient: Yes, that’s it exactly!
Coach: Great. I’d like you to write your goal in your Personal Health Record, so that at the end
of this month we can see if you are making progress and this will help you remind yourself what
your goal is.
Patient: Where do I write that?
Coach: (Pointing to the PHR page labeled ‘person goal’) Right here.
Patient: Oh, I see. (Patient writes goal in PHR). So let’s see… “feel more clear-headed and be
more steady.” Okay.
Coach: One of the things I was hoping to do with you today is to review your pills – I would like
to know what you take and how you take them. We’ll start with your pain pills (pointing to the
pill bottles the patient has gathered on the table) because sometimes they can cause that foggy
feeling you mentioned.
Patient: OK, that makes sense… I can’t tell you what a relief it is, to have someone actually
listen to what’s important to me!
Coach: I’ll bet. As we go along, we’ll probably come up with some questions for your doctor.
I’d like for you to write those down. If you turn to the last page of your Record (patient fumbles
with the PHR and find the back page), You should see a blank spot for questions.
Patient: Okay, right here.
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Coach: Right. It might be helpful to ask your doctor whether your medications need to be
changed to help you be more clear-headed.
Sample Summary Script at End of Home Visit
So we’ve gone over a lot of things today. Let’s review the most important things we’ve touched
on, including your questions and things that need to be done before I call you next time.
First, you’ve written several questions in your personal health record. What are the top three
questions you’d like to get answered when you connect with your doctor?
Remember to take this booklet with you when you go to see your doctor and update it with any
changes the two of you make.
What other things need to be done before my next call [schedule follow-up visit, get prescriptions
filled, pick up testing supplies, arrange for visiting nurse, etc.]?
I’m going to call you [later this afternoon, tomorrow, in a few days, next week] to follow up and
see how things are going and if you got your questions answered.
Do you have any other questions for me before I go? On the front of your personal health
record is my name and number. If you hit a roadblock, please call me. I’m available [schedule].
Important Transition Coaching Tips
Excellent Transition Coaches employ the following techniques when interacting with patients:



Active Listening
Open-Ended Questions
Paraphrasing/Reframing
Additional Tips
1. Transition Coaches may want to consider bring extra PHRs to the home visit, along with
pill minders (note: the patient should be encouraged to fill the pill minder with support
from the Transition Coach).
2. Transition Coaches should receive each patient’s discharge instruction sheet and review
the sheet prior to the home visit.
15
Data Collection Measures
Two data collection measures will be used for the ADRC CTI project: the Care Transition
Measure-3 (CTM-3) (p. 30) and the Patient Activation Assessment: the first represents a
patient-level measure and the second a coach-level measure. The CTM-3 is a three-item
instrument designed to assess the quality of care transitions from the acute hospital to home or to
another care setting. Transition Coaches should bring the measure with them to the home visit
and ask patients to complete it at the end of the visit. Transition Coaches should explain to
patients that the CTM-3 provides valuable feedback on the quality of care transitions patients
experience from the hospital to another care setting (a recommended Script for introducing the
CTM-3 is included in this booklet).
The Patient Activation Assessment (p. 31) is completed by Transition Coaches and assesses
each patient’s level of activation in the four pillar areas at the conclusion of the CTI intervention.
At the bottom of the Patient Activation Assessment is a section, separate from the measure, for
collecting brief demographic information on each client. A description of the scoring for the
Patient Activation Assessment is listed on page 29 of the booklet.
Patient Activation Assessment data will be entered and compiled in a CTI Patient Registry
document. A patient registry file in Microsoft Excel, formatted with patient code numbers, will
be provided to each site. The registry will allow sites to assign codes to patients volunteering to
participate in the intervention. Each patient’s CTI forms and data collection measures should be
given the code assigned through the registry, so that patient information can be linked across
measures and forms. Each site will also receive customized Microsoft Excel Workbook files to
collect and record data for the CTM-3 and the Patient Activation Assessment (as noted, the latter
includes a demographic data section). Data will be submitted quarterly on ________; _______;
_______; __________; and, ________. ADRCs should designate a staff person responsible
for entering, storing and transmitting data.
Below is a recommended script for introducing the CTM-3. **
To improve our understanding of the patient experience of moving from one care setting
to another (can substitute “hospital” or “skilled nursing facility” to “home”), we would
like to ask you if you would complete a brief three-question survey. Please know that
regardless of your decision to take the survey, your health care or eligibility to
participate in this care transition program will not be affected. If you do choose to take
the survey, we encourage you to openly and honestly answer each question. Your
answers will provide us with important feedback about how well patients are prepared
for moving from one care setting to another. In addition, your answers will help X
facility evaluate and improve on the discharge process (e.g., patients understanding of
medication and post-hospital care needs, healthcare preferences of patients) for future
patients.
16
If the patient agrees to take the survey, please read each question aloud to ascertain
comprehension. Next, explain the following response options offered for each of the three
questions:
Strongly Disagree
Disagree
Agree
Don’t Know/Don’t’ Remember/Not Applicable
Strong Agree
If the patient’s ability to comprehend the survey questions in written form is impaired (due to
literacy or mild cognitive difficulties) but the patient is able to participate with the assistance of
the Transition Coach, then the Transition Coach should assist the patient in completing the
survey, e.g., read each question aloud again, slowly, and repeat each of the response options. As
expected, in some cases the patient’s caregiver will serve as proxy for the patient both in
answering the survey and participating on behalf of the patient in the Care Transition
Intervention.
Please thank the patient/caregiver for participating in the survey.
** Remember to collect the CTM-3 at the end of the visit.
17
Project Reports
Sites are required to submit narrative interim progress reports and a final report. All reports
should be e-mailed to Karol Swartzlander - KSwartz2@chhs.ca.gov. The progress report should
be 1-2 pages in length. Progress reports are due ________; __________; and, ____________.
Each CTI narrative progress report should address the following:
1. Progress on the CTI work plan. Sites that demonstrate full and successful participation in
the project (e.g., Transitions Coaches have been trained, appropriate number of patients
have participated in the project to-date).
2. A brief summary of the most common reasons participants did not complete the
intervention (this information is collected in the Registry).
3. Unexpected successes and/or challenges – within your community, agency, or with
collaborating organizations.
4. If applicable, please provide information on any organizational or programmatic changes,
including changes in key leadership.
5. Based on your experience to date, do you anticipate successful completion of the CTI
component of the ADRC operations? Please explain.
A final narrative report is due ________. Details regarding the final report will be sent to sites in
_____________.
Sample Patient Consent Form
A sample consent form (p. 34 is included in this booklet for sites to modify and use (see Paula’s
comment. Sites should have their finalized consent forms vetted by their respective legal
departments.
Project Dates
A list of key project dates (p. 36), Transition Coach training, site visit, monthly project
conference calls, and project data and narrative reports for the 17-month project period, is
included in this booklet.
18
Tools and Forms
The Personal Health Record
Personal Health
Record
If you have questions or concerns
Contact ____________________
At # (____) ____-_______
Hours _____________________________
Call (__________________________)
At (____) ____ - _______
with questions or concerns, if you have
difficulty contacting your own primary care
doctor, specialist, or home care nurse.
Take your Record with you to all your
doctor visits.
This Personal Health Record was developed by Cedars-Sinai Medical
Center.
The Personal Health Record of:
19
Home Address:
Health and Symptoms …
Home Phone:
Notes and Questions for my Doctor or Nurse:
Other Phone:
Birth Date:
Hospital ID:
Primary Care
Provider:
Advance
Directive:
YES
NO
Caregiver Information
Name:
Home Phone:
Other Phone:
Relation to Me:
Recent Hospital Visits
Hospital
Admitted
Discharged
Reason for
Admission
Health and Symptoms …
__/__/__ to
__/__/__
Notes and Questions for my Doctor or Nurse:
20
EMERGENCY
Police, Fire,
Paramedics
Poisoning
Poison Control Center
(800) 2221222
Who/Name
Number
What
911
Doctor #1
Dentist
Pharmacy
Nearby
Relative/Friend
Out-of-State
Relative/Friend
Home Health
My Specialist Doctors
Name
Important Phone Numbers
21
Specialty
Phone
Number
____________________________________
____________________________________
____________________________________
My Medical History
Check any health problems that you have had:
The person who may speak for me
about my health care, if I am
unable to speak for myself is
Name:
Phone:
Alternate Phone:
 Allergies
 Arthritis
 Abnormal Heart Rhythm (Slow, Fast or Irregular
Heart Beat)
 Back Pain or Back Surgery
 Cancer
 Diabetes
 Deep Vein Thrombosis (DVT, Clot in leg or groin)
 Hardening of the Arteries
 Heart Disease
Where my Advance Directive is
located:
 Heart Failure (Congestive Heart Failure, CHF)
 High Blood Pressure
 Hip Fracture
 Lung Disease (for example: COPD, Emphysema,
Asthma)
 Pneumonia
 Stroke
 Other Diagnoses/Health Problems:
22
 Take this Personal Health Record with me to
wherever I go, including ALL doctor visits and future
trips to the hospital
 Call my doctor if I have questions about my
medications or if I want to change how I take my
medications
 Tell my doctors about ALL medications I am taking,
including over-the-counter drugs, vitamins and
herbal formulas
 Update my Medication Record with any changes to
my medications
 Know why I am taking each of my medications
 Know how much, when and for how long I am to
take each medication
My Advance Directives
An Advance Directive is a written document that you
have signed that states either:
 Know possible medication side effects to watch out
for and what to do if I notice any.
(1)
What your wishes for medical treatment are, if
you are unable to speak for yourself, or;
My Responsibilities
Checklist
My Personal Health
Goal
(2)
The name of someone who knows your wishes
well and can speak for you if you are unable to
speak for yourself.
Before I leave the hospital, I will be able to say …
 I have been involved in decisions about what will
take place after I leave the hospital.
 I know where I am going after I leave this hospital. I
know what will happen in the first few days after I
lave the hospital.

Pledge for My Personal Health
To better manage my health and medications, I will
23
Before I leave the hospital, I will be able to say …
 I have been involved in decisions about what will
take place after I leave the hospital.
 I know where I am going after I leave this hospital. I
know what will happen in the first few days after I
leave the hospital.
 I have someone to call if I have a problem during
my discharge.
 I understand what my medications are, how to get
them and how to take them.
 I understand the potential side effects of my
medications and whom I should call if I experience
them.
 I understand what symptoms I need to watch out for
and whom to call should I notice them.
 I understand how to keep my health problems from
becoming worse.
 My doctor or nurse has answered my most
important questions prior to leaving the hospital.
 My family or someone close to me knows that I am
coming home and what I will need once I leave the
hospital.
 If I am going directly home, I have scheduled a
follow-up appointment with my doctor, and I have
transportation to this appointment.
“Red Flags” and Warning Signs
24
Medication
Record
When to Get Help Right Away
Here is a list of things that mean you need to get
medical help right away:
 You have trouble breathing.
 You have a bad pain in the chest or stomach and
find it hard to breath, with sweating.
 You have a bad pain in the neck, shoulders, and
arms.
 All of a sudden you can’t talk.
 All of a sudden you can’t move one side of your
body.
 One side of your body feels numb.
 All of a sudden you have pain in one eye.
 All of a sudden you can’t see with one eye.
 You have bleeding that can’t be stopped.
 You have pain from a fall.
When you need help right away, call 911 or local
emergency services.
25
Date___________
Medicine the Doctor Prescribed
Name
(example) Cipro
List of Medications
(Cross out discontinued medications)
Dose
250mg,1 capsule, four
times a day – Until gone
When
Color
9am, 1pm, 5pm, 9pm
red
Why Taken?
To treat my
infection
New?







Medicine I buy and take for myself (“over-the-counter”). Check any you use.
 Laxatives
 Aspirin/other pain  Antacids
 Vitamins
 Cold medicine
 Cough medicine
 Sleeping Pills
 Allergy
Others (names)  ______________  ______________  _______________
Reactions and Allergies: (example: Penicillin
 Herbal Remedy
 ________________
Rash)
_______________________________________________________________________________
_______________________________________________________________________________
Questions for my Doctor or Nurse:
_______________________________________________________________________
26
Medication Discrepancy Tool
The Medication Discrepancy Tool (MDT) is designed to facilitate reconciliation of medication regimen across
settings and prescribers
Medication Discrepancy Event Description:
Complete one form for each discrepancy
Causes and Contributing Factors: Check all that apply
:: Italicized text suggests patient’s perspective and/or intended meaning
Patient Level
1.
2.
3.
4.
5.
Adverse Drug Reaction or side effects
Intolerance
Didn’t fill prescription
Didn’t need prescription
Money/financial barriers
Intentional non-adherence
6.
“I was told to take this but I choose not to.”
7.
Non-intentional non-adherence (i.e.: Knowledge
deficit)
“I don't understand how to take this medication.”
8.
Performance deficit 
“Maybe someone showed me, but I can’t
demonstrate to you that I can.”
System Level
13. Duplication.
9. Prescribed with known allergies/intolerances
10. Conflicting information from different
informational sources
For example, discharge instructions indicate 14.
one thing and pill bottle says another.
15.
11. Confusion between brand & generic names
12. Discharge instructions
16.
17.
18.
19.
incomplete/inaccurate/illegible
Either the patient cannot make out the
hand-writing or the information is not
written in lay terms.
Taking multiple drugs with the same action
without any rationale.
Incorrect dosage
 Incorrect quantity
 Incorrect label
Cognitive impairment not recognized
No caregiver/need for assistance not recognized
Sight/dexterity limitations not recognized
_________________________________________________________________________________________________
Resolution:
check all that apply
Advised to stop taking/start taking/change administration of medications
Discussed potential benefits and harm that may result from non-adherence
Encouraged patient to call PCP/specialist about problem
Encouraged patient to schedule an appointment with PCP/specialist to discuss problem at next visit
Encourage patient to talk to pharmacist about problem
Addressed performance/knowledge deficit
Provided resource information to facilitate adherence
Other __________________________________________________________________________________
27
CTI Coaching Activities & Processes
Medication
Self-management
Dynamic
Personal Health Record (PHR)
Red Flags
Follow-up
Patient is knowledgeable
about medications and has
management system
Patient is
knowledgeable about
indications that
condition is worsening
and how to respond
Patient schedules and
completes follow-up
visit with Primary
Care Provider and
Specialist
Coach empowers patient to
take charge of medications
and complete medication
reconciliation
Coach helps patient
identify an action plan
based on red flags of
condition and reason
for hospitalization
Coach helps patient
feel comfortable and
able to communicate
effectively with
providers, through
role play and practice
Patient understands the
importance of knowing
medications
Discuss symptoms and
possible drug reactions
Recommend Primary
Care Provider
follow-up visit
Explain PHR
Coach facilitates patient
reconciliation of pre- and
post-hospitalization meds
Coach assesses
condition(s)
Coach emphasizes
importance of the
follow-up visit
Patient reviews and updates PHR
Pillar
Goal
- Content
- Process
Hospital
Visit
Home Visit
Coach helps patient identify
discrepancies and questions
about medications. Patient
records in PHR for
clarification by doctor.
Coach helps patient practice
how to ask questions.
Coach asks patient
about symptoms that
indicate worsening
condition or side
effects of medications.
Patient identifies 3-5
main red flags to
monitor
Coach helps patient
develop questions,
practice asking
questions, and roleplaying for visit with
Primary Care
Provider
Patient understands and manages a
Personal Health Record (PHR)
Coach facilitates patient use and
ownership of PHR
Patient and coach review discharge
summary
Coach encourages patient to share
the PHR with primary care doctor
and specialist
Coach helps patient refine or
develop med management
system
Discuss any remaining
medication questions
Follow-Up
Calls
Ask the patient to
identify when/if
Primary Care Provider
should be called
28
Coach provides
advocacy in getting
appointment, if
necessary, and
revisits
communication
skills.
Discuss outcome of visit with
Primary Care Provider/Specialist:
Did patient get questions
answered? What did s/he ask?
Help develop new questions if
necessary and role-play as needed
Intervention Activities Checklist
Medication Management
Hosp
SNF
Home
2-Day
7-Day
14-Day
Hosp
SNF
Home
2-Day
7-Day
14-Day
Hosp
SNF
Home
2-Day
7-Day
14-Day
Review hospital medications
Construct complete medications list
Discuss medication management
Compare pre-hospital meds with hospital/SNF meds discharge list
Identify prescriptions that were prescribed not obtained
Identify medication discrepancies
Answer questions about medications
Encourage/observe use of patient medication
management system
Identify medications needing refills or barriers to refills
Personal Health Record (PHR)
Explain PHR
Update PHR
Reinforce the importance of bringing PHR to all future health care
encounters and show it to health professionals
Prepare for discharge
Medical Care Follow-Up
Advise/encourage patient to set f/u appointment with PCP or Specialist
Clarify whether patient will need to obtain f/u tests and/or results
Role-play appointment scheduling encounter
Identify problems that require immediate PCP or Specialist visit
Develop questions with patient for PCP or Specialist
Teach skill of writing questions to ask at PCP or Specialist follow-up
Provide teaching for how to obtain follow-up tests and results
Legend: D/C=Discharge; Dx= Diagnosis; Hosp=Hospital; SNF=Skilled Nursing Facility; PCP=Primary Care Provider2 Day = 2
Day Follow-Up Call; 7-Day=7-Day Follow-Up Call; 14-Day=14-Day Follow-Up Call
29
Red Flags
Hosp
SNF
Home
2-Day
7-Day
14-Day
Hosp
SNF
Home
2-Day
7-Day
14-Day
Discuss self management of condition(s)
Review discharge instructions
Discuss and teach self-management of condition(s)
Discuss target symptoms/side effects to monitor and what to do should they
arise
Discuss when PCP should be called
Discuss pain management
Discuss constipation
Other
Discuss patient’s personal goal and possible steps for achieving
Review discharge plan with patient and/or family caregiver
Find out discharge date to begin Care Transitions Intervention
Talk to family caregiver, if appropriate
Assess adequacy of support system and need for ongoing case management
Prepare patient to interact with home health team (RN, PT, OT)
Legend: D/C=Discharge; Dx= Diagnosis; Hosp=Hospital; SNF=Skilled Nursing Facility; PCP=Primary Care Provider
2 Day = 2 Day Follow-Up Call; 7-Day=7-Day Follow-Up Call; 14-Day=14-Day Follow-Up Call
30
Care Transition Measure-3 (CTM-3)
Patient Name/Code (Optional): __________________________ Date: __________
1. The hospital staff took my preferences and those of my family or caregiver
into account in deciding what my health care needs would be when I left the
hospital.
Strongly
Disagree
Disagree
Agree
Strongly
Agree
Don't Know/
Don't
Remember/
Not Applicable
2. When I left the hospital, I had a good understanding of the things I was
responsible for in managing my health.
Strongly
Disagree
Disagree
Agree
Strongly
Agree
Don't Know/
Don't
Remember/
Not Applicable
3. When I left the hospital, I clearly understood the purpose for taking each of
my medications.
Strongly
Disagree
Disagree
Agree
#:
Strongly
Agree
Don't Know/
Don't
Remember/
Not Applicable
____________________________
31
Patient Activation Assessment
Name/Code: __________________________ Date: __________ Patient ID#: _________________
Medication Management
Personal Health Record
(PHR)
__ Demonstrates effective use
of Medication Management
System (medication organizer,
flow chart, etc.)
__ Understands the purpose of
PHR and the importance of
updating PHR
__ Agrees to bring PHR to
every health encounter
__ For each medication,
understands the purpose,
when and how to take, and
possible side effects
__ Demonstrates ability to
accurately update medication
list
Medical Care
Follow- Up
Red Flags
__ Can schedule and follow
through on appointment(s)
__ Writes a list of questions for
PCP and/or specialist and
brings to appointment
(Note: see the Codes and
Scoring for the Patient
Activation Assessment Tool
for additional activities related
to this particular activation)
__ Demonstrates
understanding of Red Flags, or
warning signs that condition
may be worsening
__ Reacts appropriately to
Red Flags per education given
(or understands how to react
appropriately)
__ Agrees to confirm
medication list with PCP
and/or Specialist
SUM:
/4
SUM:
/2
SUM:
Each check counts for 1 point.
TOTAL SCORE:
/2
SUM:
/10
Please complete for each patient:
Age
Gender
Racial/Ethnic Status
Status Post-D/C
Principal Dx @ D/C
18-30 __ 31-50 __ 51-65 __ 66-75 __ 76-85 __ 86-95 __ 95+__
Female __ Male __
African-American __ Asian __ Latino __ White__ Other__
SNF __ Home __ Other __
Respiratory/Pulmonary __ Cardiovascular __ Endocrine/Diabetes __ Cancer__
Orthopedic __ Other __
32
/2
Scoring for the Patient Activation Assessment Tool
What is the patient’s level of activation after completion of the coaching
intervention?
Medication Management
 Patient demonstrates effective use of Medication Management System
(medication organizer, flow chart, etc.)
 For each medication, understands the purpose, when and how to take,
and possible side effects
 Demonstrates ability to accurately update medication list
 Agrees to confirm medication list with PCP and/or Specialist
PHR
 Understands the purpose of PHR and the importance of updating PHR
 Agrees to bring PHR to every health encounter
 If visits have been completed, patient shows evidence of having
taken the PHR to health visits and shared it with practitioner
Medical Care Follow-Up (with PCP/Specialist)
 Can schedule and follow through on appointment(s)
 Patient completed PCP/Specialist follow-up visit
 Writes a list of questions for PCP and/or specialist and brings to
appointment
 If visit has not occurred:
 Patient develops questions to ask PCP/Specialist, at followup visit
 Through role-playing with coach, patient demonstrates ability
to overcome common barriers in the patient-provider
interaction
 If visit has occurred
 Patient asked questions at the PCP/Specialist follow-up visit
 Patient was able to get his/her questions answered and
needs met at that visit
 Patient demonstrates ability to overcome barriers commonly
presented at follow-up visit through effective role-playing
with coach.
Red Flags
 Demonstrates understanding of Red Flags, or warning signs that condition
may be worsening
 Reacts appropriately to Red Flags per education given (or understands
how to react appropriately)
33
Scoring
For each pillar, rate the patient’s competency level at the end of the intervention by
assigning one point per bulleted item. 10 points are possible. The total score will
indicate how the patient is doing (total score of between1-5 indicates that the patient’s
level of activation in the intervention is low to average; a total score of 6-7 indicates that
patient’s activation is above average; and a total score of 8-10 indicates a strong level
of activation)..
Medication Management (4 Items)
1
2
PHR (2 Items)
1
2
Follow-up with PCP/Specialist (2 Items) 1
2
Red Flags (2 Items)
2
1
3
4
Transition Coaches are encouraged to regularly review participant PAA scores (total
scores for the PAA and CTM-3 are automatically calculated by the Excel Spreadsheet
once the data has been entered) to explore and discuss additional action for patients
with low scores (e.g., referrals to psychosocial or chronic disease case management
programs) as well as trends in PAA scores that may highlight areas of improvement
needed in the transition coaching
34
Informed Patient Consent - Sample
Name of Hospital
IMPROVING CARE TRANSITIONS PROJECT
Consent Form and authorization to Use and Disclose Health Information
Leaving the hospital can often be confusing. There are new medications to understand,
symptoms to watch for and sometimes changes in daily routine.
In order to minimize any confusion and better prepare you, we would like to invite you to
become a participant in a unique study to improve care transitions.
As part of the program we will collect certain personal and health related information
from patients and/or caregivers, including your discharge summaries. If you agree to
participate you will need to sign this authorization. The information collected will be
shared with the California Community Choices Project to improve understanding and
identification of aspects of the project that promote patient empowerment and reduce
unnecessary hospital admissions.
This information will not be used for any other purpose and will be given a number
identifier that will remain within the site – Name of Hospital.
Please sign below to authorize your participation in this project and to authorize the
collection and sharing of this information with the Improving Care Transitions Project.
Your signature on this form is an agreement to permit Huntington Hospital and their
agents and contractors to use and disclose health information relating to you for the
purposes described above.
1. The health information that may be used and disclosed includes all information
collected as part of the project described in this consent form and Authorization.
2. Researchers participating in the project may use and share your health
information in connection with the project; disclose such health information in a way
that does not identify you; disclose the health information that is collected by the
project as required by law to representatives of government agencies and other
persons who are required to watch over the safety, effectiveness and conduct of
replication studies.
35
IMPROVING CARE TRANSITIONS PROJECT
Page 2
3. Once information that could be used to identify you has been removed, the
information that has been collected may be used and re-disclosed by the study
sponsor as permitted by law.
4. Once the health information has been disclosed to a third party, federal privacy
laws may no longer protect it from further disclosure. However, the researchers and
study sponsor agree to protect your health information by using and disclosing it only
as permitted by you in this authorization. Also, no publication about the research will
be made that could reveal your identity without your specific written permission.
These limitations continue even if you revoke (take back) this authorization.
5. Please be aware that you do not have to sign this authorization, but if you do not,
you will not be allowed to participate in the project. You may change your mind and
revoke this authorization at any time. To revoke this authorization, you must write
to:
Name
Project Director
Hospital Name
Street
City CA Zip
However, if you revoke this authorization, you will no longer be eligible to participate
in the project. Also, even if you revoke this authorization, the information already
obtained may remain a part of the research.
6. This authorization is effective immediately and expires in one year.
7. You will be given a copy of this authorization after you have signed it.
8. I may inspect or obtain a copy of the health information that I am being asked
to disclose.
Printed name of participant:________________________________________
Signature of participant or caregiver:________________________________
Date
Signed:___________________
36
Key Project Dates
ADRC Enhancement
Care Transitions Project
CTI Introduction
January 21, 2010
January 22, 2010
San Francisco CAL ADRC
San Diego CAL ADRC
Transition Coach Training
February 19, 2011 (Colorado)
Conference Calls - TBD
June 2010
July 2010
August 2010
September 2010
October 2010
November 2010
December 2010
January 2011
February 2011
March 2011
April 2011
May 2011
Project Work Plan Final
April 15, 2010 – San Francisco
May 1, 2011 – San Diego
Quarterly Data & Narrative Due-Dates
July 15, 2010
October 15, 2010
February 28, 2011
*** LAST PARTICIPANT ENROLLMENT DATE:
MAY 31, 2011
Final Data & Narrative Due Dates
August 1, 2011 (Final)
Site Visit – San Diego/San Francisco
September 2011
Contact Information:
Monique Parrish – CTI Technical Consultant
925-254-0522/925-323-4265; mparrish@Lifecourse-Strategies.com
Karol Swartzlander – Community Choices Project Director
916-651-6693; KSwartz2@chhs.ca.gov
About the Conference Calls
Project conference calls are valuable opportunities for your
team to engage with and share ideas with other project
participants.
To Attend a Conference Call
Please dial 1-877-468-2134 Passcode 154135
Project Work Plan Draft Due
April 1, 2010 – San Francisco
April 15, 2010- San Diego
37