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The Care Transitions Intervention® (CTI) is an evidence-based, short-term model that complements a systems’ care team by empowering the client to develop self-care skills and helps them assume a more activated role in their health through a whole-person approach.

During a 30-day program, clients with complex care needs (and/or family caregivers) work with a Transitions Coach®, to build and practice self-management skills that will ensure their needs are met during the transition from hospital to home. A Transitions Coach® gets the time to understand, motivate, and explore what matters to the client by putting them in the driver’s seat. Together they navigate through personal skill development, taking charge of self-management tools, and gaining confidence in four key areas of health, known as the Four Pillars® (medication, primary care, personal health record, and knowing their warning signs).

The Transitions Coach® role is new — it’s whole person, patient-first care, and it works.


Reduction in Hospital Readmissions

When organizations are trained and follow CTI model fidelity, they can expect reductions in readmission rates of 20-50% (reduction depends on current readmission rate).


Net Saving Per Transitions Coach

Conservatively estimated using a panel of 350 chronically ill adults with an initial hospitalization over 12 months.


Patients Met or Exceeded Goals

The majority of patient self-identified personal care goals reflect better quality of life and improved functional status.

Patients who received the CTI® were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention. Thus, rather than simply managing post-hospital care in a reactive manner, imparting self-management skills pays dividends long after the program ends.

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