[box] “Don’t confuse information with communication.” ~ Eric A. Coleman, MD, MPH[/box]
I am learning a lot about The Care Transitions Intervention (CTI) during my time working with Allegheny County Department of Human Services Area Agency on Aging. Performance AND Evidence-based, this model provides empowering support for health care consumers in the form of coaching by:
- Informing and discussing medication self-management
- Review and understanding of a patient-centered health record
- Timely and consistent follow-up
- Noting red flags by trouble-shooting problems and finding solutions
Such work will help to avoid hospital readmission, strengthening Medicare services nation-wide. The CTI is based in the Division of Health Care Policy and Research through the University of Colorado, Denver School of Medicine. This model is being replicated throughout the United States, as governed through the Centers for Medicaid and Medicare Services (CMS). Here is a map of geographic locations as of 2012:
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