Discharge Planning Toolkit

Discharge planning involves a coordinated effort among patients/residents, caregiving professionals, family members, and community supports. It is intended to smooth the transition from facility care to a home setting or alternate facility. 

Because of the number and variety of activities that must be carried out, and the number of people and disciplines involved, quality improvement initiatives for discharge planning strongly recommend the use of checklists and tools to assure that all needs have been addressed. The purpose of this toolkit is to provide practical information and resources to facilitate and support facility efforts to meet discharge planning needs. 

Discharge Planning Toolkit (pdf)

Preparing Residents For Discharge (11:58) - recorded webinar  







                        New Requirements for Discharge Planning

Includes information on the new Mega-Rule requirements for Discharge Planning that became effective 11/28/17.

                        Procedure/Checklist for Discharge Planning

                        Tool for monitoring completion of new Mega-Rule requirements

Discharge Planning Checklist

List of actions to consider prior to and on the day of discharge

                        Assessment of Post-Discharge Needs

                        Checklist of items to include in a discharge plan

                        Readmission Risk Worksheet

                        Listing of factors for increased risk of hospital readmission.

                         Discharge Care Plan

                        Care plan that can be used as is, or incorporated into facility’s care plan format.

                        Being Sensitive to Cultural Differences

                        Factors to consider in respect to individuals' beliefs and practices; web resources

                        to gain insights about specific groups

                        Resident and Caregiver Education

Review of items which need to be considered for effective education on post-discharge care.

                        Discharge Planning: Diabetic Management Checklist

Listing to ensure inclusion of essential information needed for disease management.

Medication Reconciliation

Blank template

Medication Administration Schedule

Blank Template

Discharge Summary Suggested Content

General guideline for discharge documentation.

Discharge Summary (Form)

Blank form that can be completed and copied for resident/family/continuing care providers.

Online Resources for Discharge Planning/Preparation

Listing of web resources with useful information for staff, resident, or caregiver during the process of discharge planning.



 Tip sheets for resident/caregiver:           

                                    Medication Safety

                                    Tips for Preventing Infections

                                    Managing Constipation

                                    When to Notify A Medical Provider

                                    Safety Tips

                                    For Family Members: Recognizing Potential Problems

                                    Self-Care for the Caregiver

                                    How Advanced Age Can Affect Self-Care     

Online Resources

Listing of online websites to assist with resident and caregiver education for:

Health Conditions

Advance Directives/MOLST

Alzheimer's Disease

Anticoagulant Therapy


Chronic Obstructive Pulmonary Disease (COPD)

Congestive Heart Failure

Cultural Differences

Diabetes Mellitus

Fall Prevention

High Blood Pressure (Hypertension)

Joint Replacement Surgery

Low Vision

Medication Education

Oxygen Safety



Substance Abuse

Urinary Incontinence