Tools for Patients and Caregivers

With funding from the John A. Hartford and Robert Wood Johnson Foundations, we have designed tools to support patients as they make the transition from hospital to home. These tools, and instructions for their use, are provided below.

  1. The Personal Health Record (PHR): A patient-centered record that consists of the essential care elements for facilitating productive interdisciplinary communication during the care transition. Print out the PHR, personalize it by filling in your information, and take it with you to all medical visits. Be sure to share the PHR with your doctors and nurses, asking them the questions you have written and updating them on any changes in your medications.


  2. The Discharge Preparation Checklist: A structured checklist of critical activities designed to empower patients. Before you leave the hospital or nursing facility, be sure you have completed each of the tasks on the checklist. Talk to your doctors and nurses about what is going to happen next, find out who you should call if there are problems with your transfer or medications, and be sure you understand how to take your medications. Write down important information and the answers to your questions in your PHR.


The PHR and Discharge Preparation checklist have also been incorporated into consumer guides for health care transitions by the Regional Medical Center at Lubec. These guides can be viewed by going to any of the following sites:

The Aging and Disability Resource Center
The University of Maine Center on Aging
The Community Living Exchange Collaborative


Additional resources:

"Taking Charge: Good Medical Care for the Elderly and How to Get It" by Jeanne Hannah and Dr. Joseph Friedman. This book provides caregivers with the information necessary for them to become effective members of the caregiving team.

"How to Survive Your Hospital Stay" by Gail Van Kanegan and Michael Boyette. A step-by-step guide to taking control of the hospitalization process. Chapter 18, "Going Home", focuses specifically on the issues confronted during the transition home.

American Geriatrics Society Patient Education Forum Concise and authoritative fact sheets, in question & answer format, designed to help you communicate more effectively with your health care providers. Each Forum highlights an important topic in geriatric health care and provides answers to commonly asked questions.

Consumers Advancing Patient Safety: Transitions Toolkit The pieces included in the "Taking Charge of your Healthcare: Your Path to Being an Empowered Patient" toolkit are designed to help patients and families plan and work together with their healthcare team to ensure a safe hospital transition to follow-up care.