A discharge plan is a plan for post-hospitalization care intended to identify an individual’s need for medical and social services and resources available to help prevent re-hospitalization. A discharge plan must involve

• input from you and your representatives about your preferences and care needs after hospitalization;
• information and instructions to you and your caregivers about post-hospitalization care you need; and
• arrangement of necessary post-hospital services, transfers, and referrals to appropriate services and facilities.