The Care Transitions Intervention

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.