Enhancing the Care Transitions Intervention Protocol to Better Address the Needs of Family Caregivers

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Family caregivers play a central role in ensuring the execution of the discharge care plan.


To enhance an evidence-based model—the Care Transitions Intervention (CTI)—and to make it more responsive to the needs of family caregivers and determine its impact on a measure of activation.


Prospective cohort of 83 patient–family caregiver partnerships discharged from hospital. The domains of the CTI were modified to incorporate those areas that family caregivers identified as wanting to feel better prepared and more confident.


Family caregivers experienced a mean improvement in activation of 6 points on a 0–10 scale (p < .0001). Sixty-four percent (95% confidence interval [CI], 52–75%) of family caregivers met or exceeded self-identified goals. Transitions Coaches identified 71% (95% CI, 60–80%) of patients as having medication discrepancies or errors after hospital discharge and coached family caregivers on how to respond. The mean 3-item Care Transitions Measure score on a 0–100 scale was 80.89 (95% CI, 76.62–85.16). Almost all (99%) (95% CI, 92–100%) participants would recommend the model to a friend of family member.


The enhanced family caregiver CTI significantly improved activation, quality, goal achievement, satisfaction, and medication safety. The enhanced family caregiver CTI may have application in improving the hospital discharge experience.

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