Discharge can feel overwhelming. This guide walks patients and caregivers through key decisions — step by step — so you know exactly what to expect and what questions to ask.
1 in 4
Adults 65+ fall each year
~70%
SNF patients return home
9 in 10
Prefer to age at home
🏥 Who is this guide for? Patients and families navigating a hospital or rehabilitation discharge — or anyone planning ahead for safe, independent living at home. Takes about 5–8 minutes
and produces personalized, evidence-based recommendations.
Select what best describes your current situation:
🏨
Hospital Discharge
Currently in a hospital or rehab facility preparing to leave
🏡
Planning Ahead
At home but concerned about safety or future care needs
⚠️
Recent Fall or Change
Something changed recently and you need guidance on next steps
Step 1 of 4
About the Patient
These questions help personalize your recommendations. There are no wrong answers — choose what best reflects the current situation.
Question 1
🎂
What is the patient's age range?
Question 2
🩺
What is the primary reason for hospitalization or concern?
Question 3
👥
Who does the patient live with?
⚠️ Please answer all questions before continuing.
Step 2 of 4
Daily Activities & Function
Rate the patient's current ability — not before hospitalization. Based on the Katz ADL Index
and Lawton-Brody IADL Scale, the two gold-standard clinical assessments for discharge readiness.
Why this matters:
Independence in Activities of Daily Living (ADLs) is the strongest single predictor of safe home discharge. Loss of 3 or more ADLs significantly increases placement risk (Katz et al., JAMA
1963; Lawton & Brody, Gerontologist
1969).
Question 4
🚿
Bathing — can the patient wash their whole body safely?
Question 5
👕
Dressing — can the patient dress and undress independently?
Question 6
🚽
Toileting — can the patient get on/off the toilet and manage hygiene?
Question 7
🛏️
Transfers — can the patient move safely between bed and chair?
Question 8
🚶
Walking — can the patient move safely around the home?
Question 9
💊
Medications & Health Management — can the patient manage these independently?
⚠️ Please answer all questions before continuing.
Step 3 of 4
Home Environment & Safety
The home environment is one of the most modifiable factors in discharge safety. These questions identify barriers — and solutions — for returning home.
Did you know?
The CAPABLE Program (Community Aging in Place — Advancing Better Living for Elders) showed that OT-directed home modifications reduce functional decline by up to 30%
and significantly delay nursing home placement (Szanton et al., Health Affairs
2016).
Question 10
🚪
How do you enter the home? Are there steps at the entrance?
Question 11
🏠
Is there a bedroom AND a full bathroom on the first floor?
Question 12
⚠️
How many falls has the patient had in the past 12 months?
Question 13
🧠
Are there concerns about memory, cognition, or safety judgment?
Question 14
🔧
How open is the family to making home modifications (grab bars, ramp, shower seat, etc.)?
⚠️ Please answer all questions before continuing.
Step 4 of 4
Support System & What Matters Most
Understanding what support is available — and what the patient values most — helps identify the right level of care and the right path forward.
Question 15
🤝
Who is available to help with daily care at home?
Question 16
💛
If there is a family caregiver, how are they feeling about their role?
Question 17
⭐
What matters most to the patient right now?
Question 18
💰
What financial resources are available to support care?
