Discharge Planning

Discharge planning is the process by which a multidisciplinary team collaborates to determine the optimal disposition for the patient when they are ready to be discharged from the acute hospital setting. Planning should start early during the patient’s hospitalization to avoid delays. Planning involves input from healthcare providers, nurses, therapists, and case managers. Representatives from these clinical areas should meet daily to discuss the patient’s progress and update the plan to reflect the patient’s current needs. Some stroke patients may be able to be discharged home with outpatient or home therapies. Others will require ongoing inpatient management at acute or subacute rehabilitation facilities. Some will ultimately transition to long-term skilled nursing or assisted care living if they are unable to return home independently. Knowledge of available community resources is critical to having a collaborative discussion with the patient and their family to determine the optimal disposition for the patient.