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TransitionWell

TransitionWellTransitionWellTransitionWell

Empowered Hospital-to-Home Care Transitions

We Coach You to Thrive from Hospital to Home

248-662-5171

TransitionWell

TransitionWellTransitionWellTransitionWell

Empowered Hospital-to-Home Care Transitions

We Coach You to Thrive from Hospital to Home

248-662-5171

Welcome to TransitionWell

What We Do

The Transitions Coach® empowers clients and family caregivers to develop self-care skills, guiding them to take an active role in their health. Rather than fixing problems or providing skilled care, they model and facilitate new behaviors, offer Skill Transfer Model® opportunities, and practice communication strategies. 

Model

  Utilizing the Care Transitions Intervention® (CTI), our approach empowers clients to develop self-care skills and take an activated role in their health through a whole-person approach. Over a 30-day program, clients work with a dedicated Transitions Coach® to build and practice self-management skills crucial for a successful transition from hospital to home.

Our Vision

Our Vision

Our Vision

At TransitionWell, our vision is a healthcare landscape where individuals seamlessly transition from hospital-to-home, empowered with the skills and confidence to manage their health effectively.  Our goal is to build patients' confidence in successfully navigating common problems during care transitions reducing healthcare costs.

Our Values

Our Vision

Our Vision

Excellence | Empowerment | Innovation

We strive for excellence in providing top-notch care. We equip patients with the knowledge and confidence to manage their health, while enabling healthcare workers to reach their full potential and make a positive impact in their communities.

We embrace innovation to drive positive change and improve healthcare outcomes for all. 

The Care Transitions Intervention® (CTI)

The Care Transitions Intervention® (CTI) is a proven short-term model that enhances a care team's efforts by encouraging patients to actively engage in managing their health.


Over a 30-day period, individuals with complex care needs (and/or their family caregivers) partner with a Transitions Coach® to develop self-management skills crucial for a smooth transition from hospital to home. This intervention consists of five encounters: a hospital visit (if feasible), a home visit, and three follow-up phone calls subsequent to the home visit.


Central to the program's success is the role of the Transitions Coach®. They promptly identify what motivates and matters to the patient, empowering them to lead their own skill development journey. With the guidance of a Transitions Coach®, patients set a 30-day goal, practice skills, and gain confidence across the Four Pillars® of health.

The Four Pillars of CTI

Medication Self-Management

Client/family caregiver is knowledgeable about medications and has a medication management system. 

Use of a Patient-Centered Health Record

Client/family caregiver understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care across providers and settings. The PHR is owned and operated by the client/family caregiver. 

Primary Care and Specialist Follow-Up

Client/family caregiver schedules and completes follow-up visit with the primary care physician and/or specialist physician and is prepared to be an active participant in these interactions. 

Knowledge of Red Flags

Client/family caregiver is knowledgeable about indicators that suggest their condition is worsening and has an action plan about how to respond. 

Achieve Results with TransitionWell

Through the initial random control trial and countless demonstrations among various CTI Program Providers, the research studies show that people who receive the CTI versus those who don’t were: 

1. Significantly less likely to be readmitted to a hospital up to 5 months later

2. Less likely to incur further high cost utilization

3. More likely to achieve self-identified personal goals around symptom management and recovery

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TransitionWell, LLC

Fenton, Michigan, United States

248-662-5171

Hours

Open today

09:00 am – 05:00 pm

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