The journey from a healthcare facility back to the comfort of home is a critical phase for patients, especially those with complex care needs. The Dr. Eric Coleman Care Transitions Program, also known as the Care Transitions Intervention (CTI), is an evidence-based model designed to ensure this transition is as smooth and successful as possible. This program focuses on actively engaging patients and their family care partners in managing their health, equipping them with the necessary skills and confidence to thrive at home.
Developed by Dr. Eric Coleman, a renowned expert in care transitions, the CTI program is a short-term intervention that works alongside a patient’s existing healthcare team. It recognizes that patients are at the center of their care and empowers them to take an active role in their recovery. Over a period of 30 days, individuals enrolled in the program receive personalized support from a Transitions Coach®. This coaching is structured around five key encounters: an initial visit at the healthcare facility (when feasible), a follow-up home visit, and three subsequent phone calls.
The cornerstone of the Dr. Eric Coleman Care Transitions Program is the Transitions Coach®. These coaches are adept at quickly understanding what motivates each patient, placing the patient at the forefront of their care journey. They guide patients in developing essential self-management skills, helping them navigate their health and recovery effectively. Through the coach’s guidance, patients define a personal 30-day goal and practice specific actions to build their skills and confidence in four vital areas of health, known as the Four Pillars®.
These Four Pillars® are the foundation of patient empowerment within the Dr. Eric Coleman Care Transitions Program:
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Medication Self-Management: This pillar focuses on ensuring patients have comprehensive knowledge about their medications and establish a robust system for managing them. This includes understanding dosages, schedules, and potential side effects, leading to safer and more effective medication adherence at home.
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Use of a Patient-Centered Record: The program emphasizes the importance of a Personal Health Record (PHR). Patients learn to understand and utilize their PHR to facilitate clear communication among healthcare providers across different settings, ensuring continuity of care. Crucially, the PHR is owned and managed by the patient or their family care partner, reinforcing patient agency.
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Primary Care and Specialist Follow-Up: Timely follow-up appointments are vital for ongoing care. The Dr. Eric Coleman Care Transitions Program ensures that medical appointments with primary care physicians and specialists are scheduled and completed. Furthermore, patients are prepared to actively participate in these consultations, equipped to ask questions and advocate for their health needs.
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Knowledge of Red Flags: A key aspect of self-management is recognizing when health conditions are worsening. This pillar equips patients with the knowledge to identify indicators or “red flags” that suggest their condition is deteriorating. Critically, patients also develop an action plan outlining how to respond effectively should these red flags appear, ensuring prompt and appropriate intervention.
The overarching goal of the Transitions Coach® within the Dr. Eric Coleman Care Transitions Program is not to solve problems directly or provide skilled care. Instead, they act as facilitators, modeling and guiding patients towards new self-care behaviors. They provide opportunities for Skill Transfer®, enabling patients to apply learned skills in real-life situations, and practice effective communication strategies. By building patients’ confidence to handle common challenges during care transitions, the program significantly enhances their ability to manage their health independently and successfully recover at home.
