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Community Transition

Discharge Planning is a process, not a single event. Medicare defines discharge planning this way: “A process used to decide what a patient needs for a smooth transition from one level of care to another”.

As a result of that process, the discharge plan may be to return home or someone else’s, a rehab facility, a nursing home or some other place outside the hospital.

What You Need To Know

You should know several things about your discharge plan including:

  • Expected date of discharge.
  • Diagnosis/es at the time of discharge
  • Medications/prescriptions at the time of discharge
  • Transportation needs at the time of discharge (car, cab, wheelchair van, ambulance, bus/metro, etc.)
  • Medical equipment needs (cane, crutches, walker, wheel-chair, oxygen, hospital bed, etc)
  • Home-care needs (visiting nurse, physical/speech/ occupational therapy, home health aid, etc.)
  • Rehab needs (acute, sub-acute, outpatient)
  • Special foods and/or diet restrictions
  • Physical activity restrictions
  • Follow-up medical tests/procedures/appointments

If you have any questions or need more information about your discharge plan please ask to see the social worker/nurse case manager if you are currently in a hospital or call ADRC at (202) 724-5626 and ask for the Transition Care Specialist.

Related Information


Discharge Planning Manual

Planning Your Discharge - A Checklist
Deciding to Go Home or to a Nursing Home
Discharge Planner Reps 25 June 2009
Additional Resources (ADRC)

Service Contact: 
Contact Email: 
Contact Phone: 
(202) 724-5626
Contact Fax: 
(202) 724-2008
Contact TTY: 
Office Hours: 
Monday to Friday 8:30 am to 5 pm.
Service Location: 

500 K Street, NE

GIS Address: 
500 K Street, NE