Care Transitions Intervention
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Annual CDSME and Falls Prevention Resource Centers Meeting

Making Our Vision a Reality

April 28-30, 2015
Arlington, VA


Presentations and Handouts

Care Transitions Intervention


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Year Program First Implemented in Community Settings: 2002
Currently offered in 39 states nationwide by 600+ health care organizations


During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a “Transitions Coach,” to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity intervention comprised of a home visit and three phone calls.

Program goals are to reduce hospital readmissions and promote self-identified personal goals around symptom management and functional recovery in the care transition from hospital to home. 


Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J.  (2006). The Care Transitions Intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-8.  Retrieved from

Coleman, E. A., Smith, J. D., Frank, J. C., Min, S., Parry, C., & Kramer, A.M.  (2004).  Preparing patients and caregivers to participate in care delivered across settings: The Car e Transitions Intervention. Journal of the American Geriatrics Society, 52(11), 1817-1825.

Jencks, S.F., Williams, M.V., & Coleman, E.A. (2009).  Rehospitalizations among
patients in the fee-for-service Medicare program. The New England Journal of Medicine, 360(14), 1418-28.  Retrieved from
Kripalani, S., Jackson, A. T., Schnipper, J. L., & Coleman, E. A.  (2007).  Promoting effective transitions of care at hospital discharge: A review of the literature. Journal of Hospital Medicine, 2(5), 314-323. 
Moore, C., Wisnivesky, J., Williams, S., & McGinn, T. (2003).  Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine, 18(8), 646-651.  Retrieved from

Parry, C., & Coleman, E. A. (2010). Active roles for older adults in navigating care transitions: Lessons learned from the Care Transitions Intervention. Open Longevity Science, 4, 43-50. Retrieved from

Parry, C., Min, S., Chugh, A., Chalmers, S., & Coleman, E. A. (2009).  Further application of the Care Transitions Intervention: Results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Services Quarterly, 28, 84-99.

Voss, R., Gardner, R., Baier, R., Butterfield, K., Lehrman, S., & Gravenstein, S.  (2011).  The Care Transitions Intervention: translating from efficacy to effectiveness.  Archives of Internal Medicine, 171(14), 1232-1237.  doi:10.1001/archinternmed.2011.278





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