The Care Transitions Intervention® is also known as the CTI® and the Skill Transfer Model®. During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach®, to 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
- Target audience: Patients and family caregivers undergoing transitions across care settings (Medicare, Medicaid, Dual Eligible, Commercial, Uninsured) and all age ranges
- Health outcomes:
- Reduced hospitalization rate
- Improved patient activation score
- Patient identified personal goal elicitation and attainment
- Delivered by: Transitions Coaches are RN, MSW/LCSW, OT, Paramedics
- Program type: Individual
- Format: In-Person at Home
- Length: Four weeks
- Training: In-Person
- Professional required: Yes, licensed professionals that transfers their skills to patients and families (but do not employ their skills themselves)
- Topic(s):
- Care Transitions
- Chronic Disease
- Medication Management
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