The Care Transitions InterventionSM was developed to help improve patient quality and safety during significant transitions in care.  Recognizing that the patient and their caregivers (e.g. family, friends) “are often the only common factor moving across sites”, the model targets these individuals for an intervention designed to improve care transitions.

Specifically the model tries to achieve the following goals:

• Reductions in hospital readmission and emergency department utilization
• Reduction in medication errors during transitions in care
• Improvement in patient’s comprehension of transition care plan
• Patients will learn self-management skills aligned with the four conceptual domains or "Four Pillars" to ensure their needs are met during the transition from hospital to home

The model was designed to be truly patient centered and as such, the first step in its development was to solicit the insights of the target population. Qualitative studies were performed to learn more about the experiences of older adults and family caregivers during times of transitions.  Subjects were asked to describe approaches that they believed would provide greater support during transitions and improve their overall experience.  Results from these qualitative studies were further compared with similar national and international studies.  The Care Transitions InterventionSM was then explicitly designed to be consistent with patients’ recommendations through the Four Pillars (described in Key Elements section).

The initial development work for The Care Transitions InterventionSM was funded by the John A. Hartford Foundation and the Robert Wood Johnson Foundation.