Care Transitions

CareForce Care Transitions Services are specially designed to improve the outcome of your loved one’s transitions from hospital to community or from one care setting to another.

Approximately 20% of Medicare beneficiaries discharged from a hospital are re-admitted within 30 days after leaving inpatient care Transition services have been demonstrated through replicated research to reduce the odds of re-hospitalization for certain Medicare diagnostic groups by up to 50%.
CareForce is commited to teaching seniors from Seattle, Bellevue, and other Puget Sound communities these simple steps to help them gain more control during their healthcare transitions:

-Create a Personal Health Record
-Improve Follow-up Appointments
-Self-Manage Their Medications
-Self-Manage Their Symptoms


CareForce Promotes Active Aging

CareForce is one of the first non-Medicare funded providers to become authorized to use the Care Transition Intervention model (CTISM), developed by Dr. Eric Coleman at the University of Colorado. CTISM coaches patients and families in the use of tools and techniques to promote self-management of their condition and their care transitions. Research has shown that the Care Transition Intervention (CTISM) significantly reduces the rate of re-hospitalizations for seniors with complex care needs.

CTISM is the flagship offering in CareForce’s innovative CarePack service line. While a variety of different approaches are being tried to resolve the re-admission problem, CTISM is recognized as a leader in reducing expense and improving quality outcomes.

Our team of clinicians, trained in senior and chronic care, will develop a plan of care to specifically address key issues related to discharge or transitions in care settings. This plan of care will be based on information about treatment goals post-discharge, clinical status, and personal preference. It will address coordination among all health professionals involved, including logistical arrangements and education of the patient and family.