The Program

During a 4-week program, patients with complex care needs receive specific tools, are supported by a Transition Coach^TM, and learn self-management skills to ensure their needs are met during the transition from hospital to home.

Value Proposition

• Reducing rehospitalization helps contain costs for complex patients and improves hospital bed capacity for patients admitted with more favorable DRGs.
• The program is self-sustaining.
• The program is consistent with both Medicare Advantage and Medicare fee-for-service financial incentives.
• The program promotes better performance on new JCAHO initiatives aimed at post-hospital care.

Key Findings

Patients who received this program were:

• Significantly less likely to be readmitted.
• More likely to achieve self-identified personal goals around symptom management and functional recovery.

Findings were sustained for as long as six months after the program ended.

How Can I Learn More?

• The Care Transitions Program^SM team has helped leading health care delivery systems adapt the program to their unique environments.
• Support is available for program adoption. A training manual and DVD are available on this site to prospective health systems at no charge.

A printable overview of the Care Transitions Program^SMis available here.

The Care Transitions Intervention^SM and all of its materials are the property of the Care Transitions Program^SM. The Care Transitions Program^SM is solely authorized to provide training on the Care Transitions Intervention^SM. If another entity offers to train your organization, please contact us.

The Care Transitions Program^SM is made possible in part by the generous support of The John A. Hartford Foundation.

The Care Transitions Program^SM is based in the Division of Health Care Policy and Research at the University of Colorado Denver, School of Medicine.