4.49 Discharge Planning Prior to Leaving a Hospital or Treatment Facility


​Planning for discharge begins when a child enters a hospital or treatment facility. In order to achieve and maintain high quality care it is critical that discharge planning be included in a preoperative assessment as well as out-patient treatment and in-patient psychiatric treatment. The care needs of the child should be fully documented by the facility’s medical staff before a child is discharged.

Practice Guidance

  • ​The SSW is included/involved in the discharge process to ensure that the health care professional: 
    • Discusses patient information and the discharge plan with the parent or caregiver; 
    • Provides a copy of the discharge plan, signed by the health care professional, regarding the recovery plan for the child at home, along with a list of contact names and telephone numbers for continuing care questions or emergency situations to the parent or caregiver; 
    • Assesses the parent or caregivers understanding regarding the discharge plan and recommended follow-up care, to include the: 
      • Care needs of the patient and discharge instructions; 
      • Ability to provide the needed care; 
      • Knowledge of required appointments and administration of medication; 
      • Competence, when applicable, of any acquired skills or techniques required for the child's care; 
      • Compatibility of the home environment to meet the child’s medical needs; and 
    • Addresses any questions and/or concerns the parent or caregivers may have regarding the child’s care. 
  • Documentation should be obtained from the medical provider, regarding the medically complex child’s caregiver’s ability to competently perform the required medical care. This documentation is provided to the medically complex liaison and the Medical Support Section. A copy is also placed in the Provide case file.


The SSW:
  1. Documents in the service recordings their involvement in the discharge process and files a copy of the discharge plan in the child’s case record; 
  2. And the parent or caregiver arrange for appropriate transportation for the child prior to discharge; 
  3. Follows procedures outlined in Chapter 4 Out of Home Care (OOHC) Services to explore an alternative placement that meets the needs of the child and their required level of care if it is determined by the SSW and/or medical staff that the parent’s/caregiver’s home is not appropriate to meet the child’s needs.