Care Transitions Intervention (CTI) (Title III-D Program)

The Care Transitions Intervention is designed to address the care needs of individuals who are age 65 or older, have had hospital admissions for non-psychiatric-related conditions, live in the community, reside within prescribed geographical areas to enable home visits, have a working telephone, and have a condition that typically required post-discharge SNF or home health Care or intensive medication management. The Care Transitions Intervention Program (CTI), a four week program, helps patients by encouraging them to assert active role in their health care.

 

Patients receive specific tools and skills that are reinforced by a Transition Coach who meets with the patient prior to discharge, visits the patient’s home within the first 3 days home, and follows patients across settings for the first 30 days after leaving the hospital. The ” Four Pillars” stressed by the CTI coaches are; medication self-management, creating a Personal Health Record, coaching the patient to address key issues at their next doctor appointment, and educating patient and caregivers on red flags. At the end of the four-week program, patients will often be transferred to an ongoing case management program for further support.

  • Program Goals:
  • -Promotes self-identified personal goals around symptom management and functional recovery in the care transition from hospital to home
  • -Reduce hospital readmissions

 

  • Target Audience:
  • -Adults 65+ who are transitioning from hospital to home who meet the following criteria:
    • *Non-psychiatric-related hospital admission
    • *Community-dwelling (i.e. not a long-term care facility) residence within a predefined radius of the hospital (thereby making a home visit feasible)
    • *Have a working telephone
    • *Have at least one of 11 diagnoses documented in their record (congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, diabetes, stroke, medical and surgical back conditions (predominantly spinal stenosis), hip fracture, peripheral vascular disease, cardiac arrhythmias, deep venous thrombosis, and pulmonary embolism)

 

  • Program Description:
  • -4-week program that assists individuals with complex care needs to learn self-management skills to ensure needs are met during the transition from hospital to home
  • -4 conceptual domains:
    • *Medication self-management
    • *Use of dynamic patient-centered record
    • *Primary care and specialist follow-up
    • *Knowledge of red flags

 

  • Program Delivery: 
  • -Transitions Coach that is trained by the Care Transitions Program

 

Contact information

  • The Care Transitions Program
  • The Division of Health Care Policy & Research
  • University of Colorado Denver
  • 13199 East Mountview Blvd. Suite 400
  • Aurora, CO 80045
  • Phone: 303.724.2524
  • Fax: 303.724.2530
  • Website: https://caretransitions.org/

Reference Material

  • Parry C., Coleman E.A., Smith J.D., Frank J.C., and Kramer A.M. The Care Transitions Intervention: A Patient-Centered Approach to Facilitating Effective Transfers Between Sites of Geriatric Care. Home Health Services Quarterly, 2003; 22(3):1-18.

 

  • Chugh A., Williams M.V., Grigsby J., and Coleman E. A. Better Transitions: Improving Comprehension of Discharge Instructions. Frontiers of Health Services Management, 2009; 25(3):11-32.