Discharge planning is defined as the process that is utilized to determine what needs an individual has to making a smooth transition between hospitals to another level of care. Only the patient’s physician has the authority to authorize the patient’s release, but a nurse, social worker, case manager can complete the actual discharge planning, or other individuals assigned the responsibility. Ideally, discharge planning should always be done with a team approach. Patients, their healthcare providers, and family caregivers all play critical roles in maintaining a patient’s health after being discharged. The following aspects of a discharge plan that home health care services can assist with are:

1. Patient evaluation by a qualified professional
2. Communication with the patient or representative
3. Determination for home release or transfer to another healthcare facility
4. Identifying the need for caregiver training or support
5. Providing necessary referrals to appropriate support organizations
6. Scheduling follow-up tests or appointments