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Social Care Services Evidence Summary: Care Transition Services

This evidence summary includes a broad range of research/resources on care transitions services and is primarily focused on health 

care impact. It is not intended to be an exhaustive compilation of research/resources on this topic. The information presented in this 

summary can inform the value proposition of partnering with a community-based organization (CBO) or a network of CBOs to offer 

these services and supports as part of a strategy to address social determinants of health (SDOH).

Care transitions refer to the support provided to an individual as they transition from one care setting to another as their care needs 

change. Settings of care may include hospitals, ambulatory care, skilled nursing facilities, specialty clinics, long-term care facilities, 

rehabilitation centers, and the home.1,2 Poor transitions of care can lead to adverse health events, poor adherence to care plans, 

higher hospital readmission rates, and costly expenses. Care transition services include, but are not limited to, family caregiver 

education, health goal planning, medication adherence training, transition planning, patient-activated education and coaching, 

home visits, and risk assessments. A number of different care transitions models have emerged over the years, and studies to date 

indicate that these models have proven effective at improving health outcomes and reducing medical costs. 

For specific, further detailed information on this evidence, please review the resources listed below.

1

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html

2

https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topicslibrary/hot_topics_transitions_of_carepdf.pdf?db=web&hash=CEFB254D5EC36E4FFE30ABB20A5550E0
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Care Transitions Research and Evidence

Study Population Studied Objective of Study Type of Analysis Findings / Results

Coleman et al.

(2004)

1,393 communitydwelling adults aged 

65+ admitted to the 

hospital with one of 

nine specified 

conditions in 

Colorado

To test whether the 

intervention 

encouraged older 

patients and their 

caregivers to assert a 

more active role during 

care transitions and led 

to reduced rehospitalization rates.

Quasiexperimental 

design

The results of the study showed that 

intervention subjects had lower rates of 

re-hospitalization at 30-, 60-, and 90-

days post-hospital discharge than 

control subjects. Intervention patients 

also reported high levels of confidence 

in obtaining necessary information for 

managing their condition, 

communicating with members of the 

healthcare team, and understanding 

their medication regime.

Coleman et al.

(2006)

750 communitydwelling individuals 

admitted to the 

hospital with one of 

11 selected 

conditions in 

Colorado

To implement the Care 

Transitions Intervention 

(CTI) on patients and 

observe their 

participation in their 

health and rates of rehospitalization. 

Randomized 

control trial

The findings of the study showed that 

the individuals who received the CTI

had lower hospitalization rates at 30-

and 90-days post discharge than control 

subjects, and the mean hospital costs 

were lower at 180-days post discharge 

for the intervention group.

Epstein-Lubow 

et al. (2014)

2,747 fee-for-service 

Medicare patients 

recruited during 

inpatient 

hospitalizations at six 

hospitals in Rhode 

Island

To evaluate the 

association between 

family caregiver 

presence and patient 

completion of the CTI.

Effectiveness trial The results of the study showed that 

patients with family caregivers were 

more than five times as likely to 

complete the intervention as patients 

without caregivers. 
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Study Population Studied Objective of Study Type of Analysis Findings / Results

Kangovi et al. 

(2014)

683 eligible Medicaid 

patients and 446 

control patients

To determine if tailored 

community health 

worker intervention 

would improve posthospital outcomes 

among low socio 

economic status

patients.

Two-armed, 

single-blind, 

randomized 

clinical trial

The results of the study showed that 

intervention patients were more likely 

to obtain timely post-hospital care, 

report high-quality discharge 

communication, and shower greater 

improvement in mental health than 

control patients.

The SCAN

Foundation

(2014)

The return on 

investment (ROI) 

calculator included 

data from 16 studies 

on the 

implementation of 

coordinated care 

models as well as 

2012 Medicare data.

To utilize the ROI tool to 

provide an estimate of 

the financial returns 

associated with 

implementing each of 

the selected care 

models.

ROI The ROI analysis showed that the care 

transition programs under study had a 

positive ROI, and a number of factors 

that contribute to this positive ROI were 

highlighted.
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Additional Resources

Resource Author Description of Content Target Audience

Centers for Medicare & Medicaid 

Services

This webpage gives an overview of the 

Community-based Care Transitions Program 

(CCTP) program, its partners, and eligibility 

requirements.

Community-based organizations or health 

systems interested in learning from or 

participating in the CCTP program.

Enderlin et al. (2013) This table provides an overview of six 

different care transition interventions and 

then shows the commonalities between 

these transitional care models.

General audience- individuals, and 

organizations interested in learning more 

about the different care models that exist.

Medicaid.gov This webpage provides an overview of the 

Money Follows the Person (MFP) program 

goals, grantee information, and various 

existing initiatives.

MFP grantees or individuals or 

organizations interested in learning more 

about Medicaid’s work in this space.

Partners in Care Foundation This webpage provides a description of how 

Care Transition Choices operates, its 

partners, and the results of the transition 

intervention. 

Individuals and organizations interested in 

learning about the results of transition 

interventions.

Partnerships for Healthy Outcomes This article provides an overview of the 

Eastern Virginia Care Transitions Partnership 

(EVCTP) with information on the service 

delivery model, funding, shared governance, 

information sharing and reporting, success 

factors, and more.

Those interested in learning more about 

the EVCTP model or are creating their own 

model and are interested in learning about 

the structure and function that led EVCTP 

to success.

The Care Transitions Program This webpage provides an overview of the 

CTI program, includes information on 

supporting evidence from organizations that 

have adopted CTI, and highlights key findings.

Hospitals and health systems interested in 

adopting CTI as an intervention and want 

to review supporting data and evidence.

The SCAN Foundation This report provides data points showing 

Medicare spending for different high-cost 

health conditions, outlines the need for long 

Organizations interested in how LTSS may 

support high-cost Medicare users and 

what the ROI for screening is.
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Resource Author Description of Content Target Audience

term services and supports (LTSS), and 

describes the opportunity at hand to 

enhance the use of health risk assessments.