Nursing discharge planning connects the care provided in hospital with the care a person will need next. Its practical output is a plan the patient can use, with services, information and responsibilities arranged around that person's circumstances.
For hospitals subject to the Medicare hospital conditions of participation, CMS requires a discharge process centered on patient goals and treatment preferences. The requirements include early identification of patients needing a discharge evaluation, assessment of needed services and access to them, and updating the plan when circumstances change. Evaluations and plans must be developed by, or under the supervision of, a registered nurse, social worker or other appropriately qualified personnel.
Begin with the destination and the person
Ask what the patient expects life to look like after leaving. Establish where care will take place, who the patient wants involved and which parts of the proposed plan may be difficult.
A useful planning conversation distinguishes three questions:
- What care or support does the clinical team recommend?
- What does the patient want and feel able to do?
- Which services and practical arrangements have actually been confirmed?
A referral request belongs in the third category as work still in progress until its status is known. Keep unresolved items visible during team reviews.
Teach throughout the stay
AHRQ's IDEAL approach emphasizes patient and family participation, clear explanations, checking understanding and listening to concerns. Its discussion topics include daily life at home, medicines, warning signs, test results and follow-up appointments. Education continues during the stay, rather than being compressed into the moment of departure.
For each topic, use the patient-specific plan approved by the treating team. Ask the patient or participating caregiver to explain the next step, then address what remains unclear. A signature on a document should not be the team's only evidence that the plan is usable.
Resolve practical gaps before the handoff
Consider a fictional plan that includes equipment delivery and a home visit. A discharge note saying “equipment ordered; home health referred” leaves two questions unanswered: when will the equipment arrive, and has an agency accepted the patient?
A more useful planning record identifies the confirmed arrangements, the remaining questions and the person responsible for each answer. If the destination or available support changes, bring the plan back to the responsible team for review.
Use the organization's escalation process for a barrier that prevents the planned transition. This article does not determine whether an individual patient is ready for discharge.
Transfer the work that continues
The receiving team needs to know what has been completed and what remains open. Organize the handoff around current care needs, outstanding results or appointments, patient preferences and the contact route for clarification.
A local discharge review can examine one completed transition and ask whether the patient and receiving team received consistent information. Use the findings to improve the process, including problems that a better leaflet alone cannot solve.
Related pages address medication reconciliation, caregiver readiness and follow-up after discharge.
Sources
- State Operations Manual revision 238: hospital discharge planning guidance (accessed 2026-09-17) — CMS, March 20, 2026; discharge planning section.
- IDEAL Discharge Planning (accessed 2026-09-17) — AHRQ.