About the Care Transitions Intervention®

The Care Transitions Intervention® is also known as the CTI® and the Skill Transfer Model®. During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach®, to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity evidence-based intervention comprised of a home visit and three phone calls.

What Makes our Model Unique?

In contrast to traditional case management approaches, the Care Transitions Intervention® is a self-management model. The model draws from principles of adult learning and uses simulation to facilitate skill transfer to enhance self-management. As many of these patients are likely to experience another transition in the near future, the Care Transitions Intervention® aims to address both the patient’s current and future needs.
Using qualitative techniques, the Care Transitions Program® listened carefully to patients and family caregivers to identify and understand the key self-management skills needed to assert a more active role in their care.

Next the role of the Transitions Coach® was introduced to help impart these skills and help the individual and the family caregiver become more confident in self-care.

Patients who received this program are:

  • Significantly less likely to be readmitted to a hospital.
  • Less likely to incur further high cost utilization
  • More likely to achieve self-identified personal goals around symptom management and functional recovery.

These findings are sustained for at least six months after working with the Transitions Coach®.
The Program Structure.

Our program consists of the following components:

  • A meeting with a Transitions Coach® in the hospital (where possible—this is desirable but not essential) to discuss concerns and to engage patients and their family caregivers in the Care Transitions Intervention®.
  • Set up the Transitions Coach® in home follow-up visit and accompanying phone calls designed to increase self-management skills, personal goal attainment and provide continuity across the transition.

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