The Care Transitions Program

Eric A. Coleman, MD, MPH - Health Care Services for Improving Quality and Safety during Care Hand-offs

  • The Care Transitions Intervention®
    • About the Program
    • What is a Transitions Coach®
    • Tools for Health Professionals
    • Testimonials
  • Why adopt the Care Transitions Intervention
    • Evidence and Adoption
    • Testimonials
  • Tools and
    Resources
    • Download our Program Tools
    • On the
      Cutting Edge
    • Our Publications
    • State of the Art Goals Curriculum
  • Are You a Patient or Family Caregiver?
    • Leaving the hospital: What you must know
    • Tips for Managing care at home
    • Recognizing Red Flags
    • Your Personal Health Record
    • Managing Medication
    • Links and Resources
  • Contact Us
  • The Care Transitions Intervention®
    • About the Program
    • What is a Transitions Coach®
    • Tools for Health Professionals
    • Testimonials
  • Why adopt the Care Transitions Intervention
    • Evidence and Adoption
    • Testimonials
  • Tools and
    Resources
    • Download our Program Tools
    • On the
      Cutting Edge
    • Our Publications
    • State of the Art Goals Curriculum
  • Are You a Patient or Family Caregiver?
    • Leaving the hospital: What you must know
    • Tips for Managing care at home
    • Recognizing Red Flags
    • Your Personal Health Record
    • Managing Medication
    • Links and Resources
  • Contact Us

Evidence and Adoption

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.

grandmother and grandaughter looking at a computer screen

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!

20-50%

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.

$365K

net saving per Transitions Coach®

An Independent evaluator estimates a $110 PMPM cost savings.

Injured person icon

52%

Patients meeting or exceeding self-identified personal care goals

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

EVIDENCE FROM ORGANIZATIONS THAT HAVE ADOPTED THE CTI®

 

Eastern Virginia Care Transitions Partnership Outcomes
PDF download (2.12MB)

Meritage ACO CTI Results
PDF download (75 KB)

Dominican Sisters Family Health Service, Inc. Success Using the CTI® in the CMS CCTP
PDF download (1.1MB)

North Mississippi Medical Center Reduces Heart Failure Readmissions through CTI® and Simulation
PDF download (445KB)

CTI® Coaching Decreases Re-admission and Costs for Medicare patients
PDF download (226KB)

Finger Lakes Health System Agency demonstrates significant reduction in readmissions sustained for at least 90 days
Abstract from the 2014 AcademyHealth ARM
PDF download (288KB)

The Impact of Kaua'i Care Transition Intervention on Hospital Readmission Rates
PDF download (194 KB)

hand of elderly woman clutching a walker

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

What people are saying about the care transitions program®...

  • Health care executive testimonial

Useful Resources

Publications

Family Caregivers’ Experiences during Transitions out of the Hospital
PDF Download (111KB)

Links

Why adopt the Care Transitions Intervention

Testimonials

The Care Transitions Intervention®

About the Program What is a Transitions Coach®? Tools for Health Professionals

Why Adopt the Care Transitions Intervention®?

Overview

Evidence and Adoption

Testimonials

Tools and Resources

Download our Program Tools

On the Cutting Edge

Latest News

Our Publications

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The Care Transitions Intervention® and all of its materials are the property of the Care Transitions Program®. All content on this website is © to Eric A. Coleman, MD, MPH

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.

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.

Disclaimer: The Care Transitions Program® and its personnel assume no liability or risk for use of model, materials or any advice explicit or implicit.

The John A. Hartford Foundation Gordon and Betty More Foundation  School of Medicine Health Care Policy and Research