Discharge Planning


The State Department of Health and Office for the Aging convened a Discharge Planning Workgroup as a result of recommendations from the Most Integrated Setting Coordinating Council. Representatives from providers, professional associations, local government and consumer advocates met in Albany on five occasions to develop, from their perspective, tools for discharge planners and consumers addressing three issues:

  • Safety;
  • Discharge Planner Education and
  • Consumer Education.

The tools developed reflect the expertise and "best practice" experience of Workgroup participants and are being shared to assist with discharge planner and consumer education. They should not be considered exhaustive since it is recognized that many in the community will have additional ideas which can contribute to facilitating an individual's return to the community.

Workgroup participants developed the following tools which we hope will be helpful to discharge planners and consumers:

  1. Safety Considerations, including "Safety Concerns that Impact an Individual Wishing to Live in the Community" and "Key Elements For Effective and Safe Discharge Planning to Facilitate an Individual's Right to Chose"
  2. What the Discharge Planner Needs to Know to Effect a Safe and Efficient Transition
  3. Consumer Guide to Discharge Planning, including "What Consumers and their Families Need to Know Before Being Discharged to Home Care" and "What Consumers Needs to Know about their Abilities and Responsibilities"
  4. One model for Transitional Care Planning (including Initial Discharge Screen, High-Risk Screening Criteria, Comprehensive Assessment and Screening Assessment Flow Chart)."
  5. Discharge Planning Workgroup's letter to physicians.

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