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Care Transitions Intervention®

CTI+ Services & Benefits for ACOs

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Engaged Patients (Powerful Technology + Proven Coordinated Care Success) = Equitable Care and Sustainable Payments

CTI Ven Diagram

CTI+ improves patient engagement, reduces readmission rates, and creates opportunities and improves health outcomes. 

Combining precision software with evidence-based approaches to social care coordination, CTI+ minimizes risk and streamlines referrals for providers while improving health outcomes through skills, scaffolding, and sustainable safety nets.

With CTI+, your ACO can support both clinical and social care in a single, flexible solution. Whichever care model you’re using – Care Transitions Intervention (CTI) Coaches, Community Health Workers (CHWs), or traditional clinical practice – we can support you with industry leading referral, documentation, tracking, and reporting tools.

Addressing SDoH is Possible and Practical

ACOs understand the impact of Social Determinants of Health. Your member organizations and providers can do more than ever before by bringing patient data to your partners and community as you harness the power of our Community Health Record (CHR). By engaging local social service agencies and service providers, your ACO can transform siloed services into well-coordinated, interconnected resources that offer community members in need “no-wrong-door access” to the social and clinical services provided by your ACO.

Together we can improve patient equity and service coordination, and drive sustainable growth in service provision.

We're Your Partner in Sustainable Growth and Measurable Impact

Drive Measurable Outcomes
Over the past 10 years, our solutions have improved outcomes across the nation for statewide and community social health initiatives, with results like these:

More than 60 communities across the country are powered by CCS and CTI+
Supported social services with up to 98% closed-loop referrals
Reduced hospital readmission rates up to 70%
Reduce inappropriate utilization - saving clients $16M annually

We’ll enhance your existing referral and assessment process, leveraging your EMR data and augmenting it with innovative analytical and measurement tools.
“[We] didn’t have any systematic way to coordinate services outside of excel spreadsheets…We now have a single system for standardization and consistency, ensuring clients across the state are matched with equitable services to address social and economic needs.”Pama Joyner, Director, COVID-19 Care Coordination Project, Washington State Department of Health

Tell Real Stories with Quality Data

Transition with Ease
We’ve helped dozens of organizations like yours address complex health needs, SDoH, and payor expectations regarding improved health equity. Our powerful combination of tools help you:

  • Track, measure, and communicate costs, risks, and outcomes associated with reimbursement
  • Manage staff, partner, and payer contracts
  • Demonstrate ROI of patient engagement in managing their own health
  • Use data stories to drive sustainability

Paired with CHW and/or Care Transitions Intervention Coaching, our platform provides targeted responsiveness and tailored support to ensure patients receive the right care, at the right time, and in the right environment for equitable, whole-person care. CTI+ offers  flexibility that lets our clients meet the needs of their communities AND their care coordination workforce.

More than 60 communities and clients nationwide use our ground-breaking technology framework to blend healthcare and social services interactions into a single view of participants’ wellness needs. CTI+ seamlessly allows you to: 

  • Integrate with multiple data sources and systems, including 80+ EHRs
  • Promote ongoing program growth across – and beyond – the care lifecycle, from clinic to kitchen table
  • Connect services and education for populations with chronic care management needs

With over a decade of proven results, our technology provides the simplest, shortest path to the greatest ongoing impact for patients, families, and community stakeholders – and we can implement in as little as 30-days!

Get Data Insights
We augment your clinical data with social care coordination tracking and analytics, making it easy to be data-driven in your efforts to grow and strengthen
your programs and services, tailoring them to both individual and community needs: 

  • Track and support non-clinical program data in an easy-to-use format
  • Drill from statewide impact all the way down to the ZIP level
  • View progress and impact reports in real-time
pathway activity chart
Newly Referred Chart
Dynamic visual reporting lets your team see and share community data at all stages: from intake and assessment to service completion and reporting – making continuous quality improvement (CQI) easier to maintain.

Let's Get Started!

Give us 30 minutes to show you how to accelerate your SDoH or REACH initiatives and improve the lives of the people you serve – from wherever they seek your services.
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Discover How CTI+ Can Revolutionize Your Organization

Connect With Michelle Today!


Michelle Comeau
Vice President, Care Transitions Intervention® 

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Michelle leads CTI training, program development, and on-going engagement and support of Transitions Coaches® in the international network of CTI Program Providers. She guides new partners through a readiness process to ensure successful CTI implementation.

In her 10+ years in evidence-based health promotion programs, Michelle has worked with countless organizations to facilitate, train, and support professionals at the local, county, and state levels. Michelle served as an advocate, instructor, community-workshop leader, and a county program manager for multiple Stanford University Chronic Disease Self-Management Programs (CDSMP).

As statewide Director of Development for the Wisconsin Institute for Healthy Aging, Michelle played a key role in directing training programs, developing toolkits, and providing proactive supports to community liaisons.

Michelle is proud of her talent for guiding people to help others in the most effective and fun way possible.

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