Next Step in Care: Family Caregivers & Health Care Professionals Working Together

Toolkit: Discharge Planning


Identifying and Eliminating Gaps in Care

Determining the types of care required by the patient, matching these types of care with the identified availability and capabilities of this specific family caregiver, and formulating options for post-discharge care.


From the try this series: Informal Caregivers of Older Adults at Home: Let's PREPARE

Project RED Tool 7: Understanding and Enhancing the Role of Family Caregivers in the Re-Engineered Discharge

Discharge planning:

Points to Consider: Comparing the patient's anticipated care needs with the needs assessment of the family caregiver(s) can illuminate potential problems that can be accounted for in the discharge plan (or ongoing care plan). Once realistic options for post-discharge care have been identified,  how will the options be discussed with the family caregiver(s)?


Discussing Discharge Options with the Family Caregiver

Preparing the family caregiver with advance knowledge about the patient's discharge (including date) and with various options for care, given the patient's and caregiver's identified needs. (For more, see Needs Assessment.)


Discharge Planning Is a Family Affair

Going Home: What You Need to Know (discharge checklist for family caregivers)

Family Caregiver's Planner for Care at Home

Family Caregiver in Crisis: Using Next Step in Care

Family caregivers have varying degrees of understanding regarding various types of care, how each care type is paid for, and what impact each will have on their own roles, even if they have experienced them in the past. Health care is changing rapidly, and this means significant changes in care options. Below are transition-specific tools that health care providers can use with family caregivers to share up-to-date information needed to make informed decisions.

Leaving the hospital, going to inpatient rehabilitation

Leaving the hospital, going home

Leaving inpatient rehabilitation

From rehabilitation to long-term care

Going to the Hospital


Points to Consider: Once realistic options for post-discharge care have been identified,  how will the options be discussed with the family caregiver(s)? Although a different person may be the decision-maker (such as the patient or someone with other legal authority, such as a power of attorney or health care proxy), the family caregiver will be a primary implementer of the care plan.

To learn how discussions of discharge options with family caregivers and preparation for discharge were done by health care providers in TC-QuIC, see page 23 of the report.


Communicating with the Next Care Setting

Planning a successful transition by providing the next setting of care (such as rehab, home with home care services, hospice, or home with follow-up by the patient's own doctors or clinics) with the information needed to seamlessly begin care.


Project BOOST's Patient PASS: A Transition Record (adapt for family caregiver)

INTERACT Nursing Home Capabilities List

Project RED's Postdischarge Components of the RED (see page 23)

Points to Consider: When new services start, do the health care providers have information from your setting ready at hand and easy to use? Or are family caregivers the default reporter and historian? Is the next setting seeking additional information after the patient has transferred? Do patients come back to your setting, or back to the hospital, because the next setting of care was not appropriate for the patient's care needs? Remember, confirming the abilities of the next setting to provide care for this individual patient via direct communication can be critical. Early and effective communication regarding the patient's anticipated needs can facilitate a solid plan with better chance of success.


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