Evidence and Adoption

The CTI® is uniquely focused on providing patients and family caregivers with the skills, confidence, and tools they need to assert a more active role in their care and ensure that their needs are met. Unlike most of the current approaches available, the CTI® was co-designed with patients and families and was evaluated using the most rigorous scientific approach – randomized controlled trials.

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Our Key Findings

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. Anticipated net cost savings for a typical Transitions Coach® panel of 350 chronically ill adults with an initial hospitalization over 12 months is conservatively estimated at $365,000. Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.

Looking to be successful under bundled payment or ACOs? Here is why the CTI® is a great fit!


reduction in hospital readmissions

When organizations are trained by the Care Transitions Program® and follow model fidelity, they can expect reductions in readmission rate of 20-50% (reduction depends on current readmission rate). Reducing readmissions can also improve your CMS Star rating.


net saving per Transitions Coach®

An Independent evaluator estimates a $110 PMPM cost savings.

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Patients meeting or exceeding self-identified personal care goals

The majority of patient goals reflect better quality of life and improved functional status.

Health care services for improving quality care and safety of patients during transitions across care settings