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The Care Transition Intervention Program (CTI)
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Transitioning Home:
Care Transition Intervention Program (CTI)
Supporting frail elderly patients in their move from the hospital back home is a key component of chronic care. The transitional period between sites of care is an especially vulnerable time for patients, often characterized by conflicting medical advice, medication errors and a lack of follow-up care. These factors diminish the quality of care, thus necessitating additional treatments that might have been avoided. This intervention is designed to target these problems and ease the transition between care sites.
The Care Transitions Intervention Program (CTI) helps patients by encouraging them to assert a more 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 their 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:- Reconciliation of medications at the first home visit
- Assisting the patient to create their own Personal Health Record
- Coaching the patient to address key issues at their next doctor appointment
- Educating patient and caregivers on "Red Flags"
- At the end of the four-week program, patients will often be transferred to our ongoing Case Management program for further support.
If you have any further questions about John Muir's program, please email us.