Collaboration of Care Journey Offering Care Transitions Intervention® Training


Collaboration of Care Journey continues to support South Carolina hospitals in their efforts to reduce readmission rates by offering the Care Transitions Intervention® training created by MacArthur Fellowship winner Dr. Eric A. Coleman.

 During this four-week intervention, 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 low-cost, low-intensity evidence-based intervention is comprised of a home visit and three phone calls.


 When organizations are trained by the Care Transitions Program® and follow model fidelity, they can expect reductions in readmission rate of 20-50% depending on current readmission rate. Reducing readmissions can also improve your CMS Star rating.


 Anticipated net cost savings for a typical Transitions Coach® panel of 350 chronically ill adults with an initial hospitalization over 12 months is conservatively estimated at $365,000. Patients in this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.


 A recent program evaluation found Anthem Ohio CTI® participants had approximately 18% fewer 30-day readmissions in comparison to other members with similar acuity, diagnoses and demographics. Member engagement rates for this population was more than 50% with significant improvement in the number of post-discharge appointments. In addition, the evaluation showed CTI® participants had a total health care savings of $247.60 PMPM.


 If you are interested, SCHA and Care Transitions Intervention® will work with your hospital to develop a customized plan. The training is being offered through the Collaboration of Care Journey at a dramatically discounted rate. Normally, the Care Transitions Coach Training ® is $3,750, but we are offering this to our members for $250 per coach. If you are interested in learning more, please contact Laura Cole at or 803-454-6968.






06-25-2018 02:18 (EDT)