At a glance
Three things to know.
Start before moving day
Talk with the hospital and receiving home early.
Connect the teams
Ask who is coordinating medicines, equipment, and transport.
Keep familiar routines
Share what helps the person feel comfortable and understood.
Read the overview
You do not have to organize a move alone. A shared plan helps the family, hospital, receiving home, clinicians, pharmacy, and equipment providers understand who is doing what.
A transition map
Before, during, and after the move.
- Step 1
Start the conversation
Discuss residential fit, permission to share records, funding, and possible barriers early.
- Step 2
Prepare together
Confirm orders, medicines, equipment, supplies, training, and transport with the responsible teams.
- Step 3
Connect on arrival
The receiving team checks the handoff and raises any questions through the clinical process.
- Step 4
Keep communicating
Confirm follow-up appointments, contact people, routines, and how concerns will be shared.
One shared handoff
Six things to organize together.
Select a topic to see its details.
Topic 1 · Care information
Care information
Current summary, allergies, medication reconciliation, orders, and individualized support plans.
Topic 2 · Equipment and supplies
Equipment and supplies
Device details, prescribed settings, vendor contacts, supplies, and backup arrangements.
Topic 3 · Follow-up
Follow-up
Appointments, tests, therapies, laboratory needs, and responsible providers.
Topic 4 · The person’s routine
The person’s routine
Communication, comfort, preferences, relationships, and personal goals.
Topic 5 · People to contact
People to contact
Decision-makers, family, clinicians, coordinators, and emergency contacts.
Topic 6 · Response plan
Response plan
Individual warning signs, escalation instructions, and emergency information.
Questions families ask
A few things worth clearing up.
Who decides when discharge is appropriate?
The hospital and treating professionals determine medical readiness. Residential admission also requires the receiving provider's individual review and the necessary authorizations.
What can families contribute?
Share what helps the person feel comfortable, how they communicate, their usual routines, and changes you notice. Ask the team to explain anything that is unclear.
What if information or equipment is missing?
Raise it with the hospital and receiving team before the proposed move so they can identify the responsible person and next step.
Resource Center · Episode 05
Watch the video.
Choose a narration language in the player. Translations still being prepared are clearly marked.
English narration. Captions are controlled by the viewer.
Watch on YouTubePrepare here. Take it with you.
Prepare for the move, one conversation at a time.
Bring these prompts to the discharge and receiving teams. They can explain who is coordinating each part of the transition.
Care handoff
Ask how instructions, medicines, nutrition, equipment, and supplies are being coordinated.
Has the receiving team reviewed current orders and instructions?
Why this matters
These are questions for the teams handling the handoff, not a checklist that asks families to certify clinical readiness.
Travel & arrival
Talk through the journey and what your loved one can expect on arrival.
Is transport arranged around the person's needs?
Why this matters
Knowing what the day may look like gives the person and family a chance to share concerns and preferences.
Continuity & follow-up
Discuss familiar routines, communication, follow-up visits, and the response plan.
Do receiving staff understand communication, routines, and the response plan?
Why this matters
The move is one part of the transition. Ask who can help with questions after arrival as well.
A little preparation you can take along.
Choose English, Spanish, Haitian Creole, or Portuguese. Download the one-page PDF to type your notes in a PDF reader and save your copy, or print a blank guide to write on.
Kreyòl ayisyen
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No sign-in or personal information needed. These prompts support a conversation; they do not determine eligibility, admission, or clinical readiness.
Trusted information
