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.
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.
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.
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.
Client/family caregiver is knowledgeable about medications and has a medication management system.
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.
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.
Client/family caregiver is knowledgeable about indicators that suggest their condition is worsening and has an action plan about how to respond.
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:
