The Care Transitions Intervention

Authors
Eric A. Coleman
Technical Assistance Tool

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.
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Population Addressed
Frail Older Adults
People with Multiple Chronic Conditions
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?
Level of Evidence
Strong
What does this mean?