In 2018, nearly one in six Medicare beneficiaries returned to the hospital within 30 days after discharge, costing Medicare $35 billion a year. Many of those readmissions were likely preventable, with experts blaming poorly executed transitions from the hospital. Transitions-of-care interventions are effective in reducing preventable readmissions, improving health care quality and equity, and lowering spending.

The Care Transitions Intervention (CTI) is an evidence-based, short-term model that aims to prevent unnecessary hospital readmissions and emergency department visits and reduce overall costs. Under the program, coaches guide patients and caregivers through the transition from hospital to home enabling patients to successfully recover and manage their health and social needs.  

This profile is part of an ongoing Better Care Playbook series, In the Field: Spotlight on Complex Care Interventions, that highlights how organizations are implementing evidence-based and promising innovations to improve care for people with complex health and social needs.

*Author Harris Meyer is a freelance journalist who has been writing about health care policy and delivery since 1986.