2.10.1 Conducts an assessment to guide discharge planning, to determine patient’s/client’s conditionand if goal(s) is met.

Completes a discharge check list.
Reviews plan of care with patient/client to determine if goals have been met.

2.10.2 Reviews and discusses with the patient/client the intervention/treatment plan to determine processand readiness for follow-up/discharge.

Conducts a family conference in a community care setting for elderly patients/clients.

2.10.3 Carefully considers the need to refer to other health professionals and/or services.

Recommends an occupational therapist to conduct a home visit to assess bathroom safety.

2.10.4 Develops a follow-up/discharge plan in collaboration with the patient/client and stakeholders.

Holds a family conference with family and other treating professionals.

2.10.5 Meets terms and conditions of the contract with regard to terminating services.

Patient/client is informed that the terms of the contract have been met.

2.10.6 Reviews with the patient/client the maintenance plan and ongoing need for self management.

Reviews discharge plan and offers post-discharge follow-up.

2.10.7 Educates patient/client on the availability of services to support transition to the community.

Provides information on community programs.