Guidelines to Discharge Planning


Nearly 20 percent of residents experience an adverse event within 30 days of discharge.  Research shows that three-quarters of these discharges could have been prevented or improved.  Many of these complications can be attributed to various discharge planning problems:

  • Changes or discrepancies in medications before and after discharge

  • Inadequate preparation for resident and family related to medication, danger signs, or lifestyle changes

  • Disconnection between clinician information-giving and resident understanding

  • Discontinuity between inpatient and outpatient providers

42 C.F.R. §483.20(l) – Post Discharge Plan of Care

To ensure the continuity of care and avoid the readmission of a resident, the facility is required to develop a post-discharge plan of care. According to 42 C.R.F. §483.20(l), post-discharge plan of care means the discharge planning process, which includes assessing the continuing care needs of the resident and developing a plan designed to ensure the individual’s needs will be met after discharge from the facility into the community. The post-discharge plan of care is developed with the participation of the resident and his or her family, whom will assist the resident in adjusting to his or her new living environment, such as a private residence, assisted living, or other types of residential settings.

Discharge Planning in a Nursing Facility Setting

When a Skilled Nursing Facility (“SNF”) anticipates the discharge of a resident to another care setting or home, it must plan for discharge. The Interdisciplinary Team (“IDT”) will begin the discharge planning process for a resident upon admission to the facility. The anticipated discharge needs, barriers to discharge, and the ability of the resident and/or family to manage these needs will be assessed by the IDT. Reassessment of these needs will occur throughout the resident’s stay. Residents admitted to the facility will receive individualized discharge planning with referrals to community resources as appropriate. Prior to discharging the resident, the IDT will complete a Discharge Summary which will include a recapitulation of the resident’s stay and final summary of the resident’s status.

Interdisciplinary Team Responsibilities

Each member of the IDT plays an important role in the discharge planning. Because discharge planning is a complex activity it is crucial to that each staff member follows the appropriate policy and procedures, in addition to each individuals responsibilities pertaining to their role.

Physician Responsibilities

  • Proactively plans with resident/family for discharge;

  • Ensure all orders are complete and accurate before discharge, including medications according to the medication reconciliation process;

  • Complete a discharge summary recapitulating the resident’s stay;

  • Communicate necessary medical information to the primary care provider as indicated; and

  • Prescribe medication upon discharge as needed.

Nurse Responsibilities

  • Verify that the discharge order has been entered into the resident’s medical record;

  • Discuss medications ordered with the resident/family and obtain necessary written prescriptions;

  • Collaborate with the physician to complete the Interagency Transfer Form and/or the Discharge Instruction Form, as appropriate; and

  • Complete any required teaching for continued treatments and medication at home and document such information on the Discharge Instruction form.

Social Worker Responsibilities:

  • Provide resident/family with information about community services and resources;

  • Assist in making the necessary community referrals on behalf of the residents; and

  • Complete appropriate forms to accompany the resident upon discharge.

In collaboration with the IDT members, involving residents and families can greatly contribute the success of discharge planning to improve resident outcomes, reduce unplanned readmissions, and increase resident satisfaction.



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