Discharge or Transition Planning

Going to Another Healthcare Facility

The Next Step in Care website provides a great deal of information about transitions into and out of rehabilitation and from one type of facility to another.

Going Home or to a Family Member’s Home

Before you are released from the rehabilitation facility, consider these questions and issues:

Heading Home

Returning home after rehabilitation can be both exciting and challenging. There are many resources available to you as you plan your return home.

Safety and Mobility

Are you able to sit in a chair, walk with or without assistance, and use a cane, walker, or wheelchair? Can you easily get into and out of a chair and bed? Your ability to move around (your mobility) and your need for assistance will determine which safety precautions or adaptations need to be made in the home. Use a home safety checklist and check with your nurse, therapist, or social worker before your discharge to see if any special adaptations to your home are required.


Be sure you have a list of your medications, how much to take (dosage), and the time of day or frequency for taking the medications. Also, find out why you need the medication, who to call if you have a problem or unexpected side effect (such as nausea, vomiting, or dizziness), and how to get a refill. A pill box with dividers for days of the week and times of day may help you remember when to take your medications. These can be purchased at your local pharmacy.


If you are unable to drive, will a family member or neighbor be available to help you go to doctor’s appointments, the pharmacy, and the grocery store? If you live alone, do you have access to local dial-a-ride services, community ride services, or services provided by a local council assisting older or disabled citizens?

Medical Equipment

Will you need a cane, walker, wheelchair, hospital bed, oxygen, respirator, catheters, colostomy supplies, adult diapers, bed pan, commode, disposable gloves, or other equipment? Be sure to get a list of items from the healthcare facility and any suggestions they have on where the equipment can be found.

Ongoing Therapy

Will you need additional therapy such as speech therapy, occupational therapy, physical therapy, or nursing care for medical issues such as wound care? Will these services be covered by your insurance? Will a home healthcare agency contact you and coordinate these visits, or will you need to set up some of these appointments on your own?


Is ongoing daily care or assistance needed? Is it safe for you to be on your own, or will you need someone to be with you for personal or companion care? Is a family member available to provide the care, or will other arrangements need to be made? Not all home care agencies are alike; see AARP’s resource page for more information.


Will you need to avoid certain foods or liquids? What kind of foods should you eat and how much? Nutrition is very important to the healing process and for maintaining good health. Ask your nurse or the dietician what you need to eat or avoid eating to be as healthy as possible.

Medical Tests and Appointments

Are there additional healthcare appointments planned or tests that need to be set up? Be sure to record whom the appointment is with, the reason for the appointment, the date and time, the address or location, and the telephone number of the office or facility.

Banking and Paying Bills

If you cannot do your own banking or pay your bills, is there a family member or trusted friend who can help you? If you cannot get out of the house, would you be able to do these tasks on a computer if you set up online banking?

Food and Other Necessary Purchases

If you can’t get to a grocery store or do other shopping, can someone do it for you? Do you need assistance preparing your meals? Do you need to arrange for meal service such as Meals on Wheels?

Communicating with Family Members and Friends

Caringbridge.org provides a free way to keep friends, family members, and others in your life connected with you and your progress. Family members and friends can provide messages of love and hope through a CaringBridge Guestbook. You can also set up a planner to help coordinate and schedule tasks such as delivering meals, providing childcare, and arranging transportation. Many people are willing to step in and help if you are able to let them know what you need.

Return to Work

Employer Accommodations

The Americans with Disabilities Act (ADA) is a law that gives employees with disabilities the right to reasonable accommodations that will allow them to do their jobs. Employers are required to provide these reasonable adjustments unless doing so would pose an undue hardship on the company.

Accommodations may include (but are not limited to) the following measures:

  • providing access to the building, the office or work station, and accessible bathroom facilities
  • changing the height of desks and equipment, installing computer-screen magnifiers, or providing equipment to help those with a hearing disability
  • restructuring jobs—for example, allowing a 10-hour/day 4-day workweek—so that a worker can receive weekly medical treatments
  • providing a reasonable amount of additional unpaid leave for medical treatment
  • moving an employee to the same job in another location where better medical care is available.

For more information, read the ADA fact booklet.

Work Hardening

Work hardening is a rehabilitation program that helps restore work capacities to an injured worker through progressive work simulation. The program may include activities to help improve overall physical condition (including strength, endurance, and coordination specific to the work activity) and ways to cope with any remaining symptoms from the original problem, such as pain.

Work hardening programs are usually provided by physical or occupational therapists.

Return to School

Know Your Rights

Find helpful information for employees and students by viewing the ADA Fact Booklet and visiting the ADA website.

The ADA requires public schools to make sure that students with disabilities have equal access to educational services. A school may be required to make modifications to educational services or provide a reasonable accommodation to a student with a disability. The accommodations may include providing access to school buildings, activities and programs, effective communication, qualified interpreters, assistive listening devices, note takers, and written materials.

More information is provided at www.ADA.gov.

Glossary Conditions