Discharge Planning for Home Health Care is a comprehensive, step-by-step guide to assessing the needs of patients and establishing a coordinated hospital-to-home discharge plan. The referral format and assessment tools provide the user with an organized and systematic approach for the transition of the patient through the continuum of care. This comprehensive resource is based on current reimbursement and regulatory issues and contains over 150 tools for easy application to a broad spectrum of health care settings.