Visiting Nurse Service

Self Care Tools

 Our Care Transitions Coaching Program is modeled after the Care Transitions
Program developed by Eric Coleman, MD, MPH at the University of Colorado, Denver
( ). We will be sharing the tools they have developed which have proven
useful to many people. We will also be coaching you on some simple things you can do to manage
your health conditions as discussed below.

Personal Health Record

Your Coach will give you a Personal Health Record for you to fill 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, it is important to keep it updated and 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.

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 of consumers who were hospitalized so that it is from the patient perspective. 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. Your Coach will provide you with a medication sheet where you will be coached to write down all the medications you take (including over the counter medications like vitamins and Tylenol), and how you take them. 

  • It is important to update it with any changes in medications so your list is always current.
  • Every time you see your doctor, nurse, or pharmacist, 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.
  • 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. It is important to get in to see your doctor generally within a week or so. Your Coach can practice strategies with you to successfully get an appointment as soon as it is needed.

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 getting 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. Your Coach can help you with this…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 to come to your home to help you better manage your condition. You might ask your Coach or doctor’s office if you are eligible for these services

Reaching Your Health Goals

Your doctors and Coach 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 Coach and let them know how they can help support you!

Care Transitions Program; Denver, Colorado © 2009 Eric A. Coleman, MD, MPH   

Visiting Nurse Service of Rochester
(585) 787-2233
(800) 724-5727

2180 Empire Boulevard • Webster, NY 14580


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