My Transitional Care Plan© summarizes information to facilitate successful transitions in care for older adults presenting with, or at risk of, responsive behaviours or complex mental health, substance use or neurological conditions (166). It provides a synopsis of essential information that should be communicated to members of the interprofessional team to prepare and facilitate a transition in care. The tool is written in first person to promote person-centred care, and health and social service providers should collaborate with persons and their support network when completing the form. My Transitional Care Plan© can be built within an electronic health record. The form is also available in French (166).

Registered Nurses' Association of Ontario. (2023). Appendix H of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author.  pp 123-124

Source: Reprinted with permission from: Behavioural Supports Ontario (BSO).