Clemens Health | Discharge-to-home support coordination record
Updated 2026-10-05 | (651) 354-1196

Use with the responsible professionals. This is not a discharge clearance form, clinical plan or authorization to begin services.

Expected transition
What date is proposed and who supplied it?
Illustrative entry: Proposed return home noted by the discharge contact.
Your notes: ________________________________________

Changed routine
What daily support implications need review?
Illustrative entry: Receiving provider needs current information about the planned home routine.
Your notes: ________________________________________

Clinical owner
Who answers questions about instructions?
Illustrative entry: Named discharge or treating professional, recorded privately.
Your notes: ________________________________________

Service owner
Who reviews the support and authorization?
Illustrative entry: Responsible case manager or agency contact.
Your notes: ________________________________________

Provider readiness
What has actually been confirmed?
Illustrative entry: Intake review complete; evening worker not yet assigned.
Your notes: ________________________________________

Uncovered interval
Which time or task remains unresolved?
Illustrative entry: Return-home evening before the first confirmed visit.
Your notes: ________________________________________

Handoff closure
Who checks whether the first visit occurred?
Illustrative entry: Agreed coordinator to confirm with the person and provider.
Your notes: ________________________________________

Illustrative example
A provider accepts a referral for review before a proposed discharge. The hospital contact hears “accepted” and assumes the first evening is staffed. The readiness record shows that intake review is complete but the worker assignment remains open. The coordinator raises the uncovered evening with the discharge team and case manager. They review the actual plan instead of relying on a vague status. Clinical instructions remain with the responsible professionals, and the provider is asked only to confirm the service it can deliver.

Next step
Share the specific unresolved readiness items with the discharge team, case manager and receiving provider through their agreed coordination process.

This is an optional discussion worksheet, not an official assessment, authorization, service plan, or emergency plan. Keep completed copies private and share through an agreed channel.