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Whole-Person,
Patient-First Care
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WELCOME 
TO CTI

The Care Transitions Intervention® (CTI) is an evidence-based, short-term model
that complements a systems’ care team by empowering the client to develop
self-care skills and helps them assume a more activated role in their health
through a whole-person approach.

During a 30-day program, clients with complex care needs (and/or family
caregivers) work with a Transitions Coach®, to build and practice
self-management skills that will ensure their needs are met during the
transition from hospital to home. A Transitions Coach® gets the time to
understand, motivate, and explore what matters to the client by putting them in
the driver’s seat. Together they navigate through personal skill development,
taking charge of self-management tools, and gaining confidence in four key areas
of health, known as the Four Pillars® (medication, primary care, personal health
record, and knowing their warning signs).



The Transitions Coach® role is new — it’s whole person, patient-first care, and
it works.


20-50%

REDUCTION IN HOSPITAL READMISSIONS



When organizations are trained and follow CTI model fidelity, they can expect
reductions in readmission rates of 20-50% (reduction depends on current
readmission rate).


365K

NET SAVING PER TRANSITIONS COACH



Conservatively estimated using a panel of 350 chronically ill adults with an
initial hospitalization over 12 months.


52%

PATIENTS MET OR EXCEEDED GOALS



The majority of patient self-identified personal care goals reflect better
quality of life and improved functional status.

Patients who received the CTI® were significantly less likely to be readmitted
to the hospital, and the benefits were sustained for five months after the end
of the one-month intervention. Thus, rather than simply managing post-hospital
care in a reactive manner, imparting self-management skills pays dividends long
after the program ends.

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