Resource Location: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medicaidreadmissions.pdf
Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions is intended to help hospital-based readmission reduction teams design and deliver transitional care to address “whole-person needs” (clinical, behavioral, and social). This whole-person approach to transitional care is patient centered, data informed, evidence based, and field tested.