Our Publications
Organizations Who’ve Adopted the
Care Transitions Intervention® Model
2026. Administration for Community Living. Spotlight: Care Transitions Intervention (PDF). U.S. Department of Health and Human Services. Retrieved February 4, 2026, from https://acl.gov/sites/default/files/NCSC/spotlight-care-transitions-intervention-acl.pdf
The Better Playbook: The Care Transitions Intervention: Coaching Patients to Successfully Transition from Hospital to Home
2023. Harris Meyer. This profile highlights the interventions elements, implementations, impact, and insights on the programs value/ROI.
Collaborating to Reduce Hospital Readmissions for OA with Complex Needs: E. VA Care Transitions Partnership
2012. Reviews partnership model of 5 AAAs; 4 Health Systems, 69 Skilled Nursing Facilities, 3 MCOs to reduce hospital/nursing home readmissions and improve care for older adults.
Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance After Hospital Discharge?
Rebekah Gardner, MD1,2, Qijuan Li, MPH3, Rosa R. Baier, MPH1,3, Kristen Butterfield, MPH1, Eric A. Coleman, MD, MPH4, and Stefan Gravenstein, MD, MPH1,2,3,5,6
Dominican Sisters Family Health Service, Inc.
Suffolk County Community-based Care Transitions Program (CCTP)
The Impact of Kaua’i Care Transition Intervention on Hospital Readmission Rates
Fenfang Li, PhD; Jing Guo, PhD; Audrey Suga-Nakagawa, MPH; Ludvina K. Takahashi, BA; and June Renaud, BEd
Eastern Virginia Care Transitions Partnership: Outcomes
A formal community partnership of health systems, area agencies on aging, independent physicians’ groups, 69 skilled nursing facilities and other public and private health and human service providers.
Strategies For Sustaining Patient And Family Engagement
Shane Spees President And Ceo North Mississippi Health Services
Meritage ACO Care Transitions: Coaching, Management, and Coordination
By Andrea Kmetz, RN
Formal Publications
The Care Transitions Intervention: results of a randomized controlled trial.
Coleman EA, Parry C, Chalmers S, Min SJ. Archives of Internal Medicine. 2006;166(17):1822-1828. PMID: 17000937
Further application of The Care Transitions Intervention: results of a randomized controlled trial conducted in a fee-for-service setting.
Parry C, Min, SJ, Chugh, A, Chalmers S, Coleman, EA. Home Health Care Services Quarterly. 2009;28(2-3):84-99. PMID: 20182958. doi:10.1080/01621420903155924
Patient Outcomes After 30, 60, and 90 Days Post-Discharge in a Community-Wide, Multi-Payer Care Transitions Intervention (CTI) Program
Smirnow AM,1 Wendland M,1 Campbell P,2 Bartock B,3 Chirico J,4 Cohen E,4 & Beckman H,1,5 1Finger Lakes Health Systems Agency; 2Rochester Area Community Foundation; 3Visiting Nurse Service of Rochester and Monroe Co., Inc.; 4Lifetime Care...
Complex Care Hospital Use and Postdischarge Coaching: A Randomized Controlled Trial (for pediatric patients)
Ryan J. Coller, MD, MPH, Thomas S. Klitzner, MD, PhD,b Carlos F. Lerner, MD, MPhil, Bergen B. Nelson, MD, MS, MD, Lindsey R. Thompson, MS, MPH,Qianqian Zhao, MS, Adrianna A. Saenz, MPH, Siem Ia, CPNP, MS, RN, Jessica Flores-Vazquez...
Improving Patient Activation among Older Veterans
Journal of Gerontological Social Work (2021). Nicholas S. Koufacos, Justine May, Kimberly M. Judon, Emily Franzosa, Brian E. Dixon, Cathy C. Schubert, Ashley L. Schwartzkopf, Vivian M. Guerrero, Morgan Traylor & Kenneth S. Boockvar
Evaluation of a modified community based care transitions model to reduce costs and improve outcomes.
BMC Geriatrics 2013 13:94. Logue and Drago. doi:10.1186/1471-2318-13-94
Effectiveness of a National Transitional Care Program in Reducing Acute Care Use.
Shiou-Liang Wee, Chok-Kang Loke, Chun Liang, Ganga Ganesan, Loong-Mun Wong, and Jason Cheah, JAGS 62:747–753, 2014
Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance after Hospital Discharge?
Gardner R, Li Q, Baier RR, Butterfield K, Coleman EA, Gravenstein S. J Gen Intern Med 29(6):878–84. DOI: 10.1007/s11606-014-2814-0.
Family Caregivers’ Experiences during Transitions out of the Hospital.
Coleman EA, Roman SP. Journal for Healthcare Quality. 2015:37(1):2-11.
Patients’ and Family Caregivers’ Goals for Care During Transitions Out of the Hospital
Coleman EA, Sung-Joon M.Home Health Care Services Quarterly 34(3-4):173-184.
Enhancing the Care Transitions Intervention Protocol to Better Address the Needs of Family Caregivers.
Coleman EA, Roman SP, Hall KA, Min SJ. Journal for Healthcare Quality. 2015:37(1):12-21.
Caregiver Presence and Patient Completion of a Transitional Care Intervention.
Epstein-Lubow G, Gardner R, Baier R, Butterfield K, Coleman EA, Gravenstein S. Am J Manag Care. 2014;20(10):e439-e444
Achieving Positive ROI via Targeted Care Coordination Programs.
Avarele Consultants. The SCAN Foundation September 2014.
Disseminating Evidence-based Care into Practice.
Coleman EA, Rosenbek S, Roman SP. Popul Health Manag. 2013 Aug;16(4):227-34. PMID: 23537156. doi: 10.1089/pop.2012.0069
Association Between Quality Improvement for Care Transitions in Communities and Rehosptializations among Medicare Beneficiaries.
Brock, J, et al. Journal of the American Medical Association (JAMA) January 23/30, 2013 – Vol 309, No 4,
The Care Transitions Intervention, Translating from Efficacy to Effectiveness.
The-Care-Transitions-Intervention-Translating-From-Efficacy-to-Effectiveness.pdf
Active Roles for Older Adults in Navigating Care Transitions: Lessons Learned from the Care Transitions Intervention.
Parry C, Coleman EA. Open Longevity Science 2010;(4):43-50.
Implementation of the Care Transitions Intervention: sustainability and lessons learned. Professional Case Management.
Parrish MM, O’Malley K, Adams RI, Adams SR, Coleman EA. 2009;14(6):282-295. PMID: 19935345. doi: 10.1097/NCM.0b013e3181c3d380
A qualitative exploration of a patient-centered coaching intervention to improve care transitions in chronically ill older adults.
Parry C, Kramer HM, Coleman EA. Home Health Care Services Quarterly. 2006;25(3-4):39-53. PMID: 17062510
Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention.
Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Journal of the American Geriatrics Society. 2004;52(11):1817-1825. PMID: 15507057