The Program

During a 4-week program, patients with complex care needs receive specific tools, are supported by a Transitions Coach^®, 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^® team has helped leading health care delivery systems adapt the program to their unique environments.

The Care Transitions Intervention (CTI)^® has been carefully designed and tested and modifications or extracting parts of the model is generally not advised, particularly if the provider or organization is seeking to replicate the CTI's^® proven outcomes. The Care Transitions Program^® discourages organizations from referring to models that do not adhere to model fidelity for the CTI^® as "modified from", "based on" or "derived from" the Care Transitions Intervention^®, CTI or Coleman model. If an organization other than the Care Transitions Program^® approaches you and offers the CTI^® or something related, we ask that you please contact us. Thank you.

To implement the Care Transitions Intervention^® as designed, Transitions Coaches^® need to have completed formal training by The Care Transitions Program^®.

The Care Transitions Program^® has the exclusive authority to provide training on the Care Transitions Intervention^®. Please do not accept training offers from other entities. To learn more about our menu of training options, please click here.

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

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