This guide 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. This guide is aimed toward hospitals at all stages of readmission work and applies to teams working on Medicare, Medicaid, and all-payer target populations. The message of this guide is to expand readmission reduction efforts to include Medicaid patients, and in doing so, adapt strategies to better meet the clinical, behavioral and social transitional care needs of all high-risk patients.
