► Referrals to community resources - must demonstrate knowledge of most common resources, i.e. home health, medical equipment, Title 19, Meals-on-Wheels, mental health services.

► Discharge planning starts with the pre-admission process

► Comprehensive documentation of all activities related to discharge planning, including name and time of any phone calls, meetings or interactions.

► Communication with interdisciplinary team, resident and family

► Coordination of home health and equipment to coincide on day of discharge or earlier if training is necessary on a new piece of equipment, i.e. 4-wheeled walker, glucometer, etc.