Key Takeaways

  • Provide a care transitions coaching program to ensure individual's needs are met while transitioning from the hospital to home.

Care Transitions Intervention® is also known as CTI® and the Skill Transfer Model®. During a 30-day program, patients with complex care needs and/or family caregivers receive specific tools while they work with a Transitions Coach®. Clients 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.

Other topics include self-management, patient navigation, and patient-centered care, empowerment.

Note: Track health promotion program guidance during COVID-19 regularly for updates to program implementation and training options. Programs traditionally implemented in-person may be temporarily allowable by telephone or online.

  • Target audience: Patients and family caregivers undergoing transitions across care settings (Medicare, Medicaid, Dual Eligible, Commercial, Uninsured) and all age ranges
  • Health outcomes:
    • Decrease hospital re-admission rate
    • Improved patient activation score
    • Patient identified goal creation and success
    • Attained long-term health self-management skills
  • Delivered by: Trained Transitions Coaches® can be RN, MSW/LCSW, OT, Paramedics, CHWs, etc.
  • Program type: Individual
  • Format: In-Person, Telephonic, Video conference 
  • Length: 30-days
  • Training: In-Person, in special cases training is offered in a virtual platform
  • Professional required: Preferred not required. In this empowerment model, a Transitions Coach® must have a good understanding of the local health system to guide clients toward skill development and understanding. Coaches do not complete coordination tasks or activities, the client does. 
  • Accessibility adaptations available: N/A
  • Cultural adaptations available: The program has successfully been implemented in all 50 states of the US, as well as parts of Canada, Australia, and Singapore. Trained CTI Program Providers localize the model.
  • Available in languages other than English: The training is in English. Coaches who can speak other languages can adapt this program to non-English speaking clients. 
  • Topic(s):
    • Care Transitions
    • Chronic Disease
    • Medication Management

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