The Care Transitions Intervention

Eric A. Coleman
Implementation Tool
November 2016

This implementation resource describes the Care Transition Intervention (CTI) and provides tools to improve the quality and assess the effectiveness of care hand-overs. It also includes a tool for more productive interactions between health care professionals and family caregivers to facilitate care transitions. 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; 52 percent met or exceeded self-identified personal care goals.
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