The Care Transitions Intervention (CTI) program at Sharp Grossmont Hospital (SGH) provides 30-day post-discharge care transition coaching and community resources for underinsured or uninsured vulnerable patients (including homeless and refugee populations).

The CTI program involves a multidisciplinary team of healthcare professionals and is provided at no cost to patients by CTI “coaches” that include a registered nurse and medical social worker. Patients are identified as high-risk through SGH’s comprehensive risk assessment tool that assesses for clinical as well as social risks.

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