Discharge Planning and Transition of Care

Discharge planning is a systematic, interdisciplinary process that begins at the time of admission and ensures that patients are prepared for a safe transition from one level of care to another. The physiological basis for comprehensive discharge planning lies in understanding that patients recovering from acute illness or surgical intervention remain in a vulnerable physiological state at the time of hospital discharge. The stress response to illness activates the hypothalamic-pituitary-adrenal (HPA) axis, releasing cortisol and catecholamines that alter glucose metabolism, suppress immune function, and impair wound healing. These physiological effects persist beyond the acute hospital stay, making the post-discharge period a high-risk time for complications, medication errors, and hospital readmission. Research demonstrates that approximately 20% of patients discharged from hospital are readmitted within 30 days, and nearly 50% of these readmissions are considered preventable with adequate discharge planning. The most common reasons for preventable readmission include medication errors (patients taking incorrect doses, missing medications, or failing to fill prescriptions), inadequate understanding of warning signs requiring medical attention, premature discharge before physiological stability is achieved, and failure to establish follow-up appointments....