Transition Survival Skills

To make your transition or care "handover" from hospital to home go smoothly and to help you stay out of the hospital, there are some simple things you can do to manage your health conditions. Improving these transitions is a team sport and you and your family caregiver are key members of the team. Our Care Transitions Program® would like to share the tools we have developed which have proven useful to many people.

The Personal Health Record (PHR)

Please feel free to print this Personal Health Record, personalize it by filling in your information, and use the spaces to write down questions about your health conditions, your medications, and how to get the help you need to meet your health care needs. Once you have completed your Personal Health Record, take it with you to all medical visits and share it with your health care providers. The Personal Health Record helps make sure that you remember your questions and share your important health information.

The Discharge Preparation Checklist

The Discharge Preparation Checklist gives you permission to ask your health care professionals key questions before you leave the hospital. The checklist was created with the advice from consumers who had been hospitalized and was designed with your perspective in mind. 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 and be sure you understand how to take your medications.


For your safety, it is important for you to take ownership of your medication list.

  • Write down all the things you take, and how you take them in the medication list found in the Personal Health Record.
  • Update any changes in medications so your list is always current.
  • Every time you see your doctor, nurse, or pharmacist please share this list of medications so that everyone is "singing from the same sheet of music".
  • If you are having trouble keeping track of your medications, you might find a medication organizer helpful--just ask your doctor, nurse, or pharmacist.
  • Write down any questions about your medications - new or old - in your Personal Health Record to discuss with your doctor or pharmacist.

Follow-up Visit with your Primary Care Doctor or Specialist

Often your primary care doctor or specialist may not know you have been in the hospital. Call the office to let them know you need to get in to see your doctor soon-generally within a week or so. When you call to schedule an appointment, let the office know:

  • You have just been discharged from the hospital.
  • You need to discuss changes to your medications.
  • You have questions about how keep your health condition from being worse so that you can stay out of the hospital in the future.

When you go to your visit, bring your Personal Health Record, with your medication list and the questions you have for your doctor. As you are talking with your doctor, you can write the answers to your questions in your Personal Health Record to refer back to later.

Understanding your Health Conditions

One of the best ways to stay out of the hospital is to be able to recognize the symptoms that may signal that your condition may be worsening and to have an action plan in place for how to respond. Think back to how you were feeling before you went into the hospital-what did you notice? What did you do that seemed to help and what did you try that did not help?

  • Discuss these symptoms and your action plan with your doctor.
  • Find out whom you should call if these symptoms occur.
  • It is a good idea to have a plan during regular doctor's office hours and another plan for what to do at night and on the weekends.
  • In some cases, you may be eligible for a home care nurse or physical therapist come to your home to help you better manage your condition. You might ask your doctor's office if you are eligible for this service.

Reaching Your Health Goals

Your doctors and nurses want to partner with you to help you reach your health goals. Often reaching these goals is best accomplished with small steps. Discuss these goals and how to achieve them with your doctors and nurses and let them know how they can help support you!

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The Care Transitions Intervention® and all of its materials are the property of the Care Transitions Program®. The Care Transitions Program® is solely authorized to provide training on the Care Transitions Intervention®. If another entity offers to train your organization, please contact us.

© Eric A. Coleman, MD, MPH