The Model
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 care partners) work with a Transitions Coach®, to build and practice self-management skills that will ensure their needs are met during the transition from facility 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 management, medical care follow-up visits, personal health record, and knowing their symptom warning signs).
The Transitions Coach® role is new — it’s whole person, patient-first care, and it works.
20-72%
Reduction in Hospital Readmissions
When organizations are CTI® certified and follow model fidelity, they can expect significant reductions in readmission rates ranging from 20-50%, with some organization reporting as high at 72%. This reduction can lead to improved HEDIS and CMS Star ratings.
10X-20X ROI
When Systems & Community Collaborate
When healthcare and socialcare agencies leverage what they’re great at, utilizing the Care Transitions Intervention® as its bridge, everyone wins. It creates better health outcomes yielding a high return on investments (ROI).
The Skill Transfer Model®
significantly increases patient activation with lasting benefits
At the end of a six-month study, patients who had a 30-day Transitions Coach® had a significantly lower readmission rate of 2.4% compared to the control group which had a readmission rate of 23.8%.
Rather than only managing post-facility care in a reactive manner, Transitions Coaches® impart self-management and empowerment skills that pay dividends long after the program ends.