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Interprofessional Geriatric Transitions of Care and Discharge Planning Series

Transitions of Care occur when patients are moved from one healthcare facility to another; as result of changes in their medical condition. The consequences of poor transitions of care have resulted in readmissions, medical errors and post discharge related adverse events. Patients and their caregivers have the right to understand their personal care plans and be moved throughout the healthcare system with care, ease, and knowledge. It is up to the healthcare team to develop and provide a comprehensive, clear and concise transition care plan for the patient. In order to do so healthcare teams must understand the role each discipline plays in the transition process, communicate effectively and place the patient at the center of care.

Module 2: Discharge Planning and Home and Community-Based Services to Support Safe Transitions


Cecilia Borden, EdD
Mario Cornacchione, DO
Leigh Ann Hewston, PT, MEd
Ina Li, MD
Christine Hsieh, MD
Nancy L. Chernett, MA,MPH
Tarae Waddell-Terry, MS

Reena Antony, MPH,BSN, Christine Arenson, MD, Jennifer Bellot, PhD, RN, MHSA,
Mary Ellen Bolden, BSW, Cecilia Borden, EdD, RN, Nancy L. Chernett, MA,MPH,
Emily R. Hajjar, PharmD, BCPS, CGP, E. Adel Herge, OTD, OTR/L,
Leigh Ann Hewston, PT, MEd, Christine Hsieh, MD, Lynn Hutchings, PhD,
Stephen Kern, PhD, OTR/L, FAOTA, Ina Li, MD, Mary Ann McLane, PhD, MLS,
Veronica Rempusheski, PhD, RN, FAAN, Janet Townsend, MD,
Tracey Vause-Earland, MS, OTR/L, Tarae Waddell-Terry, MS, Valerie Weber, MD

The project described was supported by Grant Number #UB4HP19061 from the Department of Health and Human Services (HHS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Health Resources and Services Administration: Department of Health and Human Services. The project was funded 100% by the Department of Health and Human Services. The amount of federal funds used for this project totaled $ 19,967.


Medicare states that discharge planning is "A process used to decide what a patient needs for a smooth transition from one level of care to another."

Discharge Planning involves the entire healthcare team, but is often coordinated by a nurse, social worker, or case manager. This module examines the process of discharge planning to various healthcare facilities.

Learning Objectives:

Upon completion of this module, the participant will be able to:

  • Discuss general components of discharge planning to ensure a safe transition.
  • Discuss issues related to discharge from hospital to nursing facility.
  • Discuss issues related to discharge from hospital to home.
  • Provide information regarding home and community resources to ensure safe transitions.
  • Increase knowledge of the scope and benefits that are available to older adults in their homes and community.
  • Understand eligibility requirements for home and community based services.
  • To be able to provide direct access to patients and families to home and community-based services.

Estimated time for completion: 30 minutes

Since this module will take approximately 30 minutes to complete, it is designed to track your progress allowing you to complete the module in more than one sitting. The progress tracking feature allows you to return to your previous session from any computer.

Saving and Printing Responses to Questions:

Use the Save Answer button under each response text box to save your responses. Saved responses can be viewed or updated in subsequent sessions. All responses can be printed from the last screen of the module. The Print Answers button on that screen generates a PDF document that may be saved or printed.

Technical Requirements and Notes:

This learning module uses Adobe Flash media and may require you to add a browser "plug-in" in order to display properly. Most computers already have this free plug-in installed. But, if yours does not, it is very easy to download and install. Try the module first because the software is "smart" enough to detect the Flash player. If the module doesn't begin, you will be automatically prompted to download the plug-in.

The module contains links to external websites which will open in a new browser window. Your browser's back button will not return to the module, so these new windows should be closed.

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    Campus Key: 


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    WEB-ID (lastname + last four digits of your SS#, i.e. smith1234):