Community Discharge Among Long-Stay Nursing Home Residents: The Discharge Planner Perspective

Planning for discharge is common among nursing-home residents who enter the facility for a short-term rehabilitative stay. More challenging is community discharge among long-stay residents who have been in a nursing-home beyond the Medicare funded rehabilitation period. The current manuscript describes an analysis of interviews conducted with 42 nursing-home discharge planners in the context of a statewide policy to promote nursing-home to community discharge among long-stay residents. Identified themes from the analysis include a focus on newly admitted residents, starting early, multi-disciplinary planning, lack of available community services, financial concerns, and balancing resident safety with the desire to return home.