87DEVELOPING AND SCALING THE EVIDENCE-BASED CARE TRANSITIONS INTERVENTION

Abstract

The Care Transitions Intervention (CTI) was developed to address the challenges experienced by vulnerable older adults during transitions across acute and post-acute care settings. Older persons and their family caregivers are often placed in the position of assuming a major role in managing their health conditions, yet they often lack adequate skills, tools, and confidence. In contrast to traditional case management approaches, the CTI has an explicit focus on skill transfer to promote self-management. The CTI provides patients and their family caregivers with the skills, confidence, and tools they need to assert a more active role in their care and ensure that their needs are met. In this way, the CTI builds the capacity of patients and family caregivers to become more proficient in managing their self-care needs to ensure successful care transitions in the present as well as into the future. The CTI was co-designed with patients and families and was rigorously evaluated with randomized controlled trials. The findings have revealed that older patients who received the intervention were significantly less likely to be readmitted to the hospital within 30 days and the benefits were sustained for at least 180 days. Patients who received this program were also more likely to achieve self-identified personal goals addressing quality of life and functional recovery. The CTI has been successfully adopted by over 1100 health organizations in the United States as well as health organizations in Australia and Singapore. To learn more about CTI, its evidence, and adoption please visit www.caretransitions.org.