If you or a loved one has experienced post-hospitalization, it is often that patients become their own caregivers, making the process extremely difficult.

Dr. Eric Coleman at University of Colorado, School of Medicine, experienced this firsthand as a primary care physician and yearned to help individuals migrating in and out of the hospital. He was struck by the notion that complex patients lost confidence as they were instructed differently between team members and did not know who to call about important questions.

Because of this, Dr. Coleman created a thirty-day program, The Care Transitions Intervention (CTI), which pairs clients with complex care needs with a Transitions Coach. This allows patients to build self confidence in managing their skills to travel from the hospital to home. The intervention includes a hospital visit, a home visit, and three follow-up phone calls.

Hospital Care Transitions

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CTI Coach speaking with a customer
What is a CTI Transition Intervention?


The most critical aspect of the program revolves around the work of the Transitions Coaches, who are credentialed to motivate what matters to the patient and help them navigate through personal skill development. Through their guidance, patients will gain confidence, practice skills, and identify a thirty-day plan through the Four Pillars.


The four pillars include medication self-management, use of a patient-centered record, primary care and specialist follow-up, and knowledge of red flags.

The first pillar, being medication self-management, allows the client or family caregiver knowledgeable insight about medications through a management system. Secondly, the patient-centered record advocates that the client or family caregiver understands and utilizes the Personal Health Record to facilitate communication and ensure continuity of care across providers and settings. The third pillar ensures that primary care and specialist follow-up will allow patients to be seen actively by the primary care physician and/or specialist physician. Lastly, the knowledge of red flags pillar gives patients knowledgeable indicators that their condition is worsening and has an action plan about how to respond.

The Four Pillars

For more information about CTI, visit This article is provided by the CTI Team, being Michelle Comeau, Heidi Kramer, Traci Cornelius, and Lynn Schemmer-Valleau.