Discharge planning starts on day of admission.

Social workers review admission paper work including assessment of living will, advance directives, medical power of attorney and durable power of attorney, prior service providers and primary care providers, and discharge goals.  The social workers will help remove barriers to returning home such as home lay out, support system, and financial barriers.  They also ensure the proper support care is set up after discharge such as home health, outpatient, transportation assistance, caregiver support.