Beta is a DHCS-listed Care Coordination Agency for the Assisted Living Waiver.

EspañolCall (747) 293-5777
Assisted Living Waivercare coordination
Menu
CARE-130Applied foundation31 min

Notice the change. Describe it clearly. Close the loop.

Turn a vague “something is off” into timely observation, an organized handoff and confirmed next steps without diagnosing beyond your role.

Give the next responsible person information they can act on, and know whether they actually received it.

Begin courseReview sources

Before you begin

What you should be able to do

  • Describe an observed change from the person's usual baseline without diagnosing.
  • Recognize when emergency or urgent escalation is required by the person's plan and site procedure.
  • Use a concise situation-background-assessment/request structure within role boundaries.
  • Confirm receipt, responsibility and the next review point.
Lesson 16 minutes

Start with the person's baseline

“Normal” is not one universal setting. The useful comparison is this person's usual pattern.

  • Know the current plan and the observations your role is expected to make.
  • Describe what changed: behavior, alertness, breathing, movement, intake, output, skin, pain expression, communication or another relevant sign.
  • Include when it began, whether it is worsening and what happened around the change.
  • Use measurable details when available within your role; do not invent precision.
  • A sudden change in cognition should not be casually labeled as routine dementia progression.
Evidence for this lesson
Knowledge checkWhich statement best describes a change from baseline?

Choose an answer to reveal the rationale. A correct answer completes this lesson.

Lesson 26 minutes

Use the plan and procedure to set urgency

A handoff tool organizes communication. It never replaces emergency action.

  • For immediate danger or a medical emergency, activate the site's emergency process and call 911 as appropriate.
  • Use the person's plan and current site escalation procedure for urgent and routine changes.
  • Do not wait for the next shift when the procedure requires immediate contact.
  • If the designated person cannot be reached, use the approved backup and document the exception.

Try the decision

Do not polish the emergency

A resident has severe trouble breathing. The correct task is emergency action, not spending five minutes perfecting an SBAR note before calling for help.

Evidence for this lesson
Knowledge checkWhat is the role of a structured handoff during an emergency?

Choose an answer to reveal the rationale. A correct answer completes this lesson.

Lesson 37 minutes

Build an actionable handoff

The listener needs a signal, useful context and a clear request, not the complete history of Tuesday.

  • Situation: identify yourself, the person, the immediate concern and current safety status.
  • Background: give only relevant baseline, recent events, plan instructions and known context.
  • Assessment within role: describe observations and why the change concerns you; do not diagnose.
  • Request: state what response, guidance or evaluation you need and by when.
  • Use the receiver's words in the record when they give a direction, and read back critical details when appropriate.

Pocket sequence

  1. Situation: what changed now?
  2. Background: what does the receiver need?
  3. Observation: what did you see/hear/measure?
  4. Request: what response is needed?
  5. Check-back: who owns the next action and when?
Evidence for this lesson
  • TeamSTEPPS ToolsAHRQ-TEAMSTEPPS · Module 1 communication tools and Module 2 team-leadership tools
Knowledge checkWhich request closes an actionable handoff?

Choose an answer to reveal the rationale. A correct answer completes this lesson.

Lesson 46 minutes

Confirm that the message landed

Sent is a technical status. Understood and owned are operational statuses.

  • Confirm the recipient heard or received the critical information.
  • Use check-back or repeat-back for names, doses, times, destinations or other critical details when within the approved workflow.
  • Record the next action, owner and review time.
  • Escalate silence, rejection or conflicting instructions through the approved chain.
  • At shift handoff, state what remains unresolved instead of burying it in a long note.
Evidence for this lesson
  • TeamSTEPPS ToolsAHRQ-TEAMSTEPPS · Module 1 communication tools and Module 2 team-leadership tools
Knowledge checkWhich fact demonstrates a closed loop?

Choose an answer to reveal the rationale. A correct answer completes this lesson.

Lesson 56 minutes

Document the story someone else must continue

A good note lets the next person act without guessing which part was observation, instruction or unfinished work.

  • Record the change, comparison to baseline, time, immediate action and people contacted.
  • Separate your observations, the person's statement and another professional's direction.
  • Record failed contacts and the approved alternate route used.
  • State the next observation or follow-up point and who owns it.
  • Correct the record transparently; never backdate or erase the history.
Evidence for this lesson
Knowledge checkWhich final sentence is most useful?

Choose an answer to reveal the rationale. A correct answer completes this lesson.

Completion

Complete every knowledge check to unlock the record.

5 lessons remain. Use the lesson links to return to unfinished checks.

Evidence shelf

Sources behind this course

These links are the current authority shelf for this pilot. Each lesson names the source IDs it uses. Open the original for the exact rule, form or instruction that applies to real work.

AHRQ-TEAMSTEPPS · AHRQ

TeamSTEPPS Tools

SBAR, closed-loop communication, check-back, handoff and team tools

Locator: Module 1 communication tools and Module 2 team-leadership tools

Open source →
AHRQ-LTC-CHANGE · AHRQ

Change in Condition resources for long-term care

Structured recognition and communication concepts; residential-care adaptation required

Locator: Detecting Change in a Resident's Condition training materials

Open source →
CDSS-DEMENTIA · California CDSS

Dementia care information and resources

California RCFE dementia guidance and current implementation resources

Locator: Current dementia-care regulatory resources, FAQs, forms and presentation

Open source →