The primary roles of the transition coach were to encourage
the patient and caregiver to assert a more active role during
care transitions, to provide continuity across settings,
and to ensure that the patient’s needs were being met irrespective
of the care setting. Transition coaches were
advanced practice nurses; however, rather than functioning
as another care provider, the transition coaches facilitated
the patient’s and the caregiver’s roles in self-care. Therefore,
key attributes of transition coaches included competence in
medication review and reconciliation, experience in helping
patients communicate their needs to different health care
professionals, and the ability to shift from doing things for
the patient to encouraging him or her to do as much as possible
independently