Discharge Planning

Discharge Planning

We locate the facility, explain the discharge procedure, and communicate with social workers on your behalf.

    • Evaluation of the patient is performed by an RN along with Certified Assisted Living Managers.
    • Discussion with the patient or his representative
    • Planning for homecoming or transfer to another care facility
    • Determining whether caregiver training or other support is needed
    • Referrals to a home care agency and/or appropriate support organizations in the community
    • Arranging for follow-up appointments or tests

The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home. It also should include information on whether the patientʼs condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation, and chores; and possibly a referral to home care services.

Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, and can also help in recovery, ensure medications are prescribed and given correctly, and adequately prepare you to take over your loved oneʼs care.

What should the discharge plan include?

The discharge process and plan should address the following items:
• Your loved one’s condition and any likely problems or changes that could occur at home;
• A determination of Medicare or insurance eligibility for the recommended discharge services, e.g., rehabilitation, skilled nursing, home health, adult day services;
• Establishment of home care services, and necessary equipment rentals or home modifications;
• Referral to community-based services, e.g., adult day services or case management to help coordinate and manage post-discharge services;
• A review of all medications taken prior to admission and all the medications prescribed to be taken post discharge to ensure no duplications, omissions or harmful side effects;
• A complete written medication list with dosage instructions;
• The teaching and practicing of specific patient care procedures;
• Dates and times of follow-up appointments;
• A 24-hour phone number for the caregiver to call to speak with a health care professional regarding any health and care-related concerns; and
• Transportation home.

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Senior Care Placement Testimonials

Mary Berry was very instrumental in finding an assisted living facility for my friend! We were in desperate need to find our friend an assisted living facility in a matter of days and we definitely could not have found a facility for my friend without Mary’s help. Mary was knowledgeable, kind, and professional. We really appreciate everything you did for us and our friend. Thanks so much!  

Michael Johnson 

Diana M. says she wasn't sure what to do but after speaking with Ms. Berry, she was grateful and knew that something good was going to come from the conversation.  She knew her mom would be well taken care of.

Diana M

​​My wife and I learned about your company through the internet. Your services were actually what we were looking for and the reviews were very good. We met with Mary who was very professional and laid out exactly what types of services that your company would be providing. Mary had a list of 7 facilities to visit. By the time we saw the fourth facility we were very pleased by the facility and the individuals who were running it and agreed to have my mother moved from her existing facility. Mary made all of the transfer arrangements both for my mom and for her personal property. This was extremely helpful as my and wife and I are out of state and really needed her help and support. We are very pleased and more than satisfied with your companies services and would recommend you highly to anyone who might inquire.

Jim & Jan Mitchell