Resource Location: https://caretransitions.org/about-the-care-transitions-intervention/
The Care Transitions Intervention® is also known as the CTI® and the Skill Transfer Model®. 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 evidence-based intervention comprised of a home visit and three phone calls.