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Coordinated-Transitional Care Toolkit

This tool was developed by the University of Wisconsin-Madison School of Medicine & Public
Health and the William S Middleton Memorial Veterans Hospital. The Coordinated-Transitional
Care (C-TraC) Toolkit is a low-resource, telephone-based, protocol-driven program designed to
reduce 30-day rehospitalizations and to improve care transitions during the early post-hospital
period. The goal of this toolkit is to help hospital systems that serve populations with high rates
of patient dispersion, cognitive impairment, and vulnerability improve care coordination and
post-discharge outcomes such as reduced medication discrepancies. The toolkit is designed to
help clinicians and researchers execute the C-TraC program protocol. In addition to the full
toolkit, C-TraC developed a COMPASS module to support hospital to nursing home transitions.

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