Discharge Planning

When a doctor orders home health care services for you or your loved one, there is typically a limit for how frequently and for how long you will receive it. To make sure that you will be able to meet your needs when your treatment ends, your social worker will begin discharge planning at your very first meeting.

Your VNSNY social worker will review your physician’s orders, and will incorporate these orders with the bio-psychosocial assessment. Your social worker will work with you and your caregivers to identify your individual needs, and to develop a plan of care that meets them now and as they change as your condition improves.

The goals of successful discharge planning are to:

  • Ensure you can remain at home safely.
  • Link you to appropriate community resources.
  • Make sure you have adequate caregiver support.
  • Address emotional, social, and physical needs so you can return to optimal levels.
  • Give you the tools you need to maintain your health and reduce the risk of returning to the hospital.
  • Refer you to long term home care services when necessary.

Your social worker will help to coordinate care with all members of your home health care team to ensure safe and timely discharge of home care. At VNSNY, we want you to be satisfied with our services every step of the way.


For more information about VNSNY’s social work services, including discharge planning, please call us at 1-800-675-0391.