Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.

Agency for Healthcare Research and Quality; AHRQ; Boutwell A, Bourgoin A; Maxwell J; DeAngelis K; Genetti S; Savuto M; Snow J

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.