This chapter provides information on building internal infrastructure; staffing models and workflow; ensuring person-centeredness; costs and billing procedures; integrating core functions across programs (I and A, options and benefits counseling, and CT; VDC, evidence-based disease prevention).

Additional Resources

• Care Transitions December Peer Hour: Michigan Hospital Transitions
• Federal Hospital Care Transitions Resources and the Aging and Disability Network
• National Center for the Advancement of Person-Centered Practices and Systems

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