"I felt secure knowing that I could reach my Transitions Coach® when I needed help."
~ patient testimonial

The Program

During a 4-week program, patients with complex care needs receive specific tools, are supported by a Transitions Coach®, and learn self-management skills to ensure their needs are met during the transition from hospital to home.

Value Proposition

  • Reducing rehospitalization helps contain costs for complex patients and improves hospital bed capacity for patients admitted with more favorable DRGs.
  • The program is self-sustaining.
  • The program is consistent with both Medicare Advantage and Medicare fee-for-service financial incentives.
  • The program promotes better performance on new JCAHO initiatives aimed at post-hospital care.

Key Findings

Patients who received this program were:

  • Significantly less likely to be readmitted.
  • More likely to achieve self-identified personal goals around symptom management and functional recovery.

Findings were sustained for as long as six months after the program ended.

How Can I Learn More?

  • The Care Transitions Program® team has helped leading health care delivery systems adapt the program to their unique environments.


The Care Transitions Intervention (CTI)® has been carefully designed and tested and modifications or extracting parts of the model is generally not advised, particularly if the provider or organization is seeking to replicate the CTI's® proven outcomes. The Care Transitions Program® discourages organizations from referring to models that do not adhere to model fidelity for the CTI® as "modified from", "based on" or "derived from" the Care Transitions Intervention®, CTI or Coleman model. If an organization other than the Care Transitions Program® approaches you and offers the CTI® or something related, we ask that you please contact us. Thank you.

To implement the Care Transitions Intervention® as designed, Transitions Coaches® need to have completed formal training by The Care Transitions Program®.

The Care Transitions Program® has the exclusive authority to provide training on the Care Transitions Intervention®. Please do not accept training offers from other entities. To learn more about our menu of training options, please click here.


A printable overview of the Care Transitions Program®is available here.


    The Care Transitions Intervention® and all of its materials are the property of the Care Transitions Program®. The Care Transitions Program® is solely authorized to provide training on the Care Transitions Intervention®. If another entity offers to train your organization, please contact us.