Discharge Planning
Definition: The process of developing a plan for the resident's transfer from the nursing home back to a community setting, another facility, or a different level of care. Must begin at admission and be updated regularly.
In Practice
Effective discharge planning involves the resident, family, interdisciplinary team, and receiving providers. The plan must include medication reconciliation, follow-up appointments, education on self-care, and coordination with community resources. Poor discharge planning can result in hospital readmissions and survey deficiencies.