Care Transitions

Organization: CTI (Care Transitions Intervention)

This 30-day evidence-based intervention is comprised of 5 encounters: a hospital visit, a home visit (occurring 1-3 days post-discharge), and three follow-up phone calls. Its aim is to decrease readmission rates, increase patients’ wellbeing, and support agency sustainability (as revenue and/or entry point to other services).

 During the 30-day empowerment program a client (and/or family caregiver) will work with a Transitions Coach® to learn key health self-management skills related to their recent in-patient stay. Transitions Coaches® are unique, dedicated, short-term positions that does no direct service or care coordination, instead they support new behaviors to help clients gain tools to be more activated in their health and better utilize their care network (both in the health system and community) which has long-lasting benefits. We train your staff in the models’ framework and philosophy.

Note: a Transitions Coach® position is in addition to a clients’ clinical care team (e.g., visiting nurse, CHWs, case managers, primary providers, etc.) and is both a value-add and complement. Clients acquire skills that help with their current transition, future healthcare encounters, and with their own daily management.

Virtual/In-Person/Hybrid: Virtual

Cost: $3,000/student

Registration: Taking the training is one piece in an overall implementation process. Please connect with us to have an initial exploratory conversation where we discuss crucial elements that ensure successful, sustaining, program execution.

Contact: Michelle Comeau, 414-269-2664 michelle.comeau@ccs.health

Website: caretransitions.health