The Care Transitions Intervention

Guide
Key Questions Answered
  • How does the Care Transitions Intervention (CTI®) work meet clinicians’ needs and empower patients to actively manage their care?
  • What are the outcomes I can expect?
  • What are some examples of organizations that have used the CTI® successfully?
Key Themes and Takeaways

This resource describes the CTI®, which provides patients and caregivers with the skills and tools necessary for individuals to assume a more active role in their care. The CTI® was co-designed with patients and families and was evaluated using randomized controlled trials.

  • Patients who received the CTI® were significantly less likely to be readmitted to the hospital, and the benefits lasted for five months after the end of the one-month intervention.
  • Anticipated net cost savings for a typical panel of 350 chronically ill adults with an initial hospitalization over 12 months is estimated to be at least $365,000.
  • Patients who participated in this program were more likely to achieve self-identified personal goals around symptom management and functional recovery; fifty-two percent met or exceeded self-identified personal care goals.
  • When organizations are trained by the Care Transitions Program®, they can expect reductions in admission rates of 20–50 percent.
  • The site includes case studies on organizations that used the approach, including Dominican Sisters Family Health Service, North Mississippi Medical Center, and Finger Lakes Health System Agency.
Authors
Eric A. Coleman
Population Addressed
Frail Older Adults
People with Multiple Chronic Conditions
Level of Evidence
Randomized Controlled Trial; Strong Evidence
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