ABSTRACT
Discharge planning is a process of transition that prepares a family unit, including the patient, for securing adequate home care or community services or arranging transfer of the patient from one residential setting to another. Effective discharge planning and follow-up requires a clinical social work framework (Caroff & Mailick, 1985). It requires a biopsychosocial assessment, efficient identification of patients and families in need of help, skilled supportive treatment of patient and/or family, knowledge about and ability to make effective referrals, linkage, case advocacy, and evaluation of the planning and follow-up process. Social workers' interventions consist of all of the sets of techniques used in clinical social work, with a focus on relocation of patients from the medical facility to their own home or to an alternative residence or from their own home to another setting. Zelinka states that the goal is "discharge to the most suitable environment for continued good health care as soon as the patient's medical condition stabilizes".
