Process whereby an individual’s transition from a medical or nursing facility to a different level of care is coordinated.
Effective discharge planning (DP) is an ongoing process that begins upon admission. This process involves assessment of (1) the individual’s goals and expectations for post-discharge functioning; (2) psychosocial resources and instrumental support available to them; (3) physical, cognitive, and psychosocial barriers to discharge; and (4) the expected level of functioning and care needs upon discharge. The individual patient, their loved ones, and all members of their treatment team assist in gathering and documenting this information. As an individual’s admission progresses, these factors are reassessed, and addressing discrepancies between patient expectations and actual physical recovery becomes central to the DP process. By the date of discharge, discrepancies must be...