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Care and Discharge Planning

A Guide for Service Providers

Serial No: 032/SDD19/DEC06


Page Acknowledgements Feedback Foreword 2 3 4

Chapters 1 2 3 4 5 6 Introduction Components Of A Care And Discharge Plan Guiding Principles Workflow The Process Checklists 7 10 12 14 15 18

Annexes References

19 28



The National Council of Social Service would like to acknowledge the following organisations for their invaluable inputs to the development of this guide: · Disability Information and Referral Centre · Hua Mei Care Management Service · Ministry of Community Development, Youth and Sports · Methodist Welfare Services · Society for the Physically Disabled · Singapore Anti Narcotics Association



This document is published in November 2006 and will be reviewed periodically. NCSS welcomes your feedback.

Please write in to: Strategy and Specialisation Department Service Development Division National Council of Social Service 170 Ghim Moh Road #01-02 Singapore 279621 A copy of this guide can be downloaded from NCSS website. ontent4.html [Visit NCSS website; go to "VWO Corner"; Resources; and scroll down to Service Guides]

© National Council of Social Service. All rights reserved. No part of this manual may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without written permission from the National Council of Social Service.



Purpose This guide is part of a series of guides 1 on good practices for service delivery. These guides compliment the Best Practice Guidelines 2 checklist for Voluntary Welfare Organisations (VWOs) and Non-Profit Organisations (NPOs) to conduct selfassessment of their organisational practices and processes.

2 It is hoped that the guide will help improve processes to achieve the programmes outcomes for its clients. This guide is designed to provide a reference on care and discharge planning processes for community-based social service agencies in Singapore. It also serves to highlight the minimum standards which agencies should strive to achieve. The minimum standard for Care and Discharge Planning as outlined in the Service Standards Requirements are:

Care Planning (1) (2) The programme has written procedures on individual care planning. Care plans are tailored individually to meet the unique needs and preferences of the service user and/or his/her family. Re-assessment of care plans are conducted at regular intervals (at least 6 monthly) or as agreed between NCSS and the VWO.


Discharge Planning (1) (2) The programme has written procedures on discharge planning. Discharge plans are discussed at the onset of service provision with the service user, his/her family and concerned individuals involved in the care of the service user.

1 Other Guides already published are: Guidelines for Practising Therapists in VWOs (2003); Standards of Practice For Physiotherapists, Occupational Therapists & Speech-Language Therapists (2003); Specialised Caregiver Services - A Guide for Service Providers (2004); Case Management Service - A General Guide for Service Providers (2004); and Intake and Assessment - A Guide for Service Providers (2006). 2 The Best Practice Guidelines, currently a self-assessment checklist of 54 areas, will be streamlined to the Service Standards Requirements (SSR) from April 2007. The SSR is a set of 16 mandatory requirements which have a direct impact on client outcomes.



This guide consists of: · · · the guiding principles for the development and delivery of quality care and discharge planning; the processes for the development of the care and discharge plans; and, checklists and templates for care and discharge planning.

4 Organisations are expected to develop and customise their care and discharge policies and procedures using pointers from this guide. The framework recognises that the nature and clientele of each programme varies, and accordingly, the availability of human and financial resources. These factors will influence the type and extent of care and discharge plans adopted for each client.

Target audience 5 This guide is designed primarily for organisations that provide communitybased social services for persons with disability, seniors, children, youth and families in the community, in Singapore. The programmes are typically client-centred, as opposed to group-based programmes. However, agencies which conduct group programmes and mass outreach may also adopt a care plan for their vulnerable clients.


This guide is intended for the following programmes: · · · · · · · · · · · · · · · · · · Aftercare Case Management Service Befriending Services Caregiver Support Service Client Re-integration and Family Services Community Case Management Service Counselling Centres Day Care Centres for Seniors (Social, Dementia and Rehabilitation) Early Intervention Programme for Infants and Children Family Service Centres Home Help Service Home Therapy Hostels ­ Disability and Mental Health Integration Support Programmes Production Workshop Mentoring Services School Social Work Sheltered Workshops (employment services) Training and Transition Programmes 5


Other organisations involved in the care of clients.




What is a care and discharge plan?

1 A care plan puts down on paper who is providing which service to meet the needs of the client. Goals and outcomes are set, and a plan of action is decided within specified timeframes, in consultation with the client, and their caregivers, if any.

2 A discharge plan puts down on paper the end-goals of the care plan, which ultimately aims to empower the client to make decisions and be resilient, to maximise his potential to live independently, or to enable him to tap on support and resources within his family or the community. Discharge planning is a process used to decide what a client needs to maintain his present level of well-being or to move on to the next level of care.

B 3

How does it benefit clients? Clients benefit from care and discharge planning because it: · · · · Sets goals with and for the client and provider according to clients needs; Encourages a team approach by both formal and informal caregivers; Manages long-term care by setting milestones; and Ensures continuity of care.


Why do we need the plan?

4 A documented care and discharge plan would help all parties involved in the care of the client, and the client himself, to have a clear understanding and expectation of the plan of action, including his expected discharge. Without the plan, ambiguities may arise as to the role and expectations of service providers, as well as the


motivation of the client to engage actively in the programme. The care plan spells out milestones of achievement as well as decides on the agreed outcomes of intervention. D Why is it important to conduct care and discharge planning together?

5 In the business of caring and providing social service, it is important for service providers not to under or over-provide for the client. A discharge plan, when planned at the start of engaging the client, helps providers bear in mind the ultimate aim of providing supportive services to the client. i.e., to empower the client to maximise his potential and autonomy given his abilities and unique conditions.


Who needs care and discharge planning?

6 Clients who have multiple or complex needs arising from the interaction of physical, medical, social and emotional needs will benefit from a clearly documented care plan. They need skilled assessment and comprehensive management of services. They typically require well-coordinated care and supportive services, and there is a need for ongoing monitoring and review of the clients changing care needs. Examples of clients who would benefit from a care and discharge plan would be frail older persons who live alone or with minimal family support, children and adults with disabilities and ex-offenders.


When is care and discharge planning conducted?

7 Care and discharge planning should be conducted within an optimal timeframe for clients. Organisations should develop their own timeline for care and discharge plans, in tandem with its philosophy of care and intended client outcomes. 8 Usually, care and discharge planning would be conducted after intake assessment. For more information on intake assessment, refer to NCSS Guide on Intake and Assessment (2006). 9 Agencies can use the electronic Case Management System (eCMS) to document care plans. eCMS allows for information sharing across service providers, which would facilitate referral, monitoring of client progress and follow-up.


Who is involved in care and discharge planning?

10 The case manager would take the lead to implement, co-ordinate and monitor the progress of care and clients readiness for discharge. The client and caregiver (parent, guardian or family) and/or significant others should also be actively engaged and consulted in the care and discharge planning. If necessary, a multi-disciplinary


team involving various professionals would assess the client and recommend strategies and a plan of action to achieve the agreed outcomes.




Care planning should include consideration of the following: (1) (2) (3) Strengths, Needs, Abilities and Preferences (SNAP) of the client; An interpretive summary; Specific, Measurable, Achievable, Realistic and Time-bound (SMART) milestones and outcomes; Intervention plans and community partners to achieve goals; Transition and discharge plans, including criteria for discharge or transfer; and, Roles of client, family/caregiver, staff, volunteers and others in the support network (e.g. neighbours).

(4) (5)



Discharge planning should include consideration of the following: (1) The clients current condition (physical, mental and social condition), and any changes that may have occurred as a result of intervention /service rendered; Anticipated symptoms, problems or changes that may occur after discharge, including factors of stability within clients circle of support, or factors of uncertainty which may tilt the clients life equilibrium; Recommendations for follow-up care or services; The potential impact of caregiving on the caregiver, and caregiver needs, training and resources; Community and sources of social support for client and caregivers, including agencies that provide services such as transportation,


(3) (4)



equipment maintenance, respite care, home care, job referral and volunteer services; (6) Information resources such as pamphlets, videos, books and websites; and, Contact details (including name of contact person, telephone and email) of the discharging organisation for information or help.




13 The following are some guiding principles to consider in care and discharge planning.



14 A caseworker should proactively engage and empower the client (and caregiver, if any), carefully consider his preferences, and be sensitive to his unique life experience and circumstances. The care plan should be appropriate to the clients culture and age, and based on his strengths, needs, abilities and preferences. Caseworkers, in the helping effort, apart from focussing on the clients needs, should give due understanding of the clients strengths, abilities and preferences, which can be tapped on to ensure success of intervention. The caseworker should also tap on the clients natural support network, such as family, neighbours and nearest provider to his home.



15 The care plan should be flexible to address changes in the clients circumstances and environment, reviewed regularly and modified accordingly. This will ensure that the care plan remains relevant. The client should be asked for his concensus and kept informed of any changes made to the care plans. If the agency is unable to provide a particular service to address the clients needs, this should also be recorded. The agency should then refer the client to a provider who can meet the needs, and follow-up accordingly.


Communication to client

16 A caseworker should explain the purpose, benefits and process of care planning to the client and caregivers, and address their concerns. The care plan should be conveyed to the client in a manner and at a level and pace that is appropriate to their: · personal background (profession, religious and ethnic sensitivities);


· language and preferred ways of communicating; · their current intellectual, mental and emotional states; and, · the presence of any physical impairment (e.g. hearing and visual).


Enhance quality of life

17 When assessing a client, the caseworker needs to be open and honest about what action plans are critical and necessary, and what is open to compromise and negotiation. There is a need to prioritise the action plan, as not all changes can be effected immediately. Caseworkers must be aware that their individual values, cultural background and principles may influence their assessments. The driving principle should be that the changes proposed should enhance the quality of life of the client and his family, or caregivers.


Respect client confidentiality

18 The client or clients parent/guardian should be informed that personal information may or will be shared with other various service providers, if necessary, to ensure continuity of care. The caseworker should hence obtain the clients or his parents/guardian consent through signing of a consent form, and respect his wishes if there is any personal information that he does not wish to be disclosed to any particular person or agency. Due discretion must be applied. The above may not apply to emergency situations, or where the safety of the client may be compromised. The client should also be informed that his personal information may be required for typically aggregated statistical studies of trends and patterns; service reviews or service planning. Refer to Annex 1 for guiding principles of information sharing.


Acknowledged by client and provider

19 Both client and provider should sign the care plan after it has been presented to him. In the event that the client is unable to do so, the caregiver can be asked to acknowledge the plan.


Chapter 4 WORKFLOW

Intake assessment

Chart 1: Care and Discharge Planning Process


Needs assessment, if necessary by a multi-disciplinary team

Interpretive summary

Establish care and discharge plan in consultation with client and caregiver/significant others

Implement care plan

Monitor outcomes, review care plans according to clients changing needs and progress

Prepare for discharge ­ detailed discharge plan, including follow-up plans


Follow-up 14

Chapter 5



Intake assessment

20 Assessment is a way of learning important information about a client so that his critical and real needs are ascertained and appropriate service determined. Assessment should include the clients physical and mental health profile; family and social history; formal and informal support systems, activities of daily living, mental and emotional status, community and financial resources, interests, hobbies and past work history 3 . The key assessor in charge of putting together the care plan is required to get a "whole picture" of the clients circumstance to best and most effectively meet the needs of the client. If possible, the caregiver should attend the initial assessment with the client to give a more holistic picture of the client.

21 It is important to note that clients with special needs and concerns may require additional assessments such as speech, audiology or psychological evaluation. A home visit can be conducted, if necessary, during this stage or when feasible to identify home safety issues, home medication use, use of or need for adaptive devices and the optimal functioning of the client and caregiver at home 4 .



22 The client is admitted to the programme if he meets the agencys eligibility criteria. The eligibility criteria should be transparent to users and well-documented.


Needs assessment

23 It would be ideal if all who are involved in the care and discharge of the client meet to discuss on the care and discharge plans. However, this may not be possible in some cases. Agencies can be flexible in terms of where and how the planning is conducted. Care must be taken to ensure that all parties, including the client, agree with the plan, to understand and agree on each partys role and responsibilities. As

3 4

Reference: Guidebook on Dementia Day Care Centres, Ministry of Health, Singapore, 2002 Ibid.


the plan may involve professionals from one or multiple agencies, due care must be taken to ensure minimal misunderstanding or miscommunication.


Interpretive summary

24 Once the clients strengths, needs, abilities and preferences are identified in the intake or needs assessment, the case manager should develop an interpretive summary. This summary indicates the caseworkers diagnosis or interpretation of the clients needs based on information obtained during assessment. The summary links co-occurring issues and makes a professional judgment on the connections between all issues raised in order to prioritise goals and intervention.


Establish care and discharge plan

25 The care plan lists and prioritises set specific, measurable, achievable and realistic outcome/s within an optimal timeframe. Important milestones should also be set and clearly stated to measure progress. The goals/desired outcomes should be described in terms of observable client response. This would help motivate the client and the caseworker as there is a sense of achievement, particularly when difficult lifestyle changes need to be made.


Implement care plans

26 Whilst implementing the intervention strategies to achieve the stated outcomes, it is important to involve and empower the client, and ensure self-determination as far as possible. Monitoring of the progress of the client should be conducted systematically, at scheduled review dates or when the clients circumstances had changed.



27 Discharge planning should start at the time or even prior to admission. The purpose of discharge planning is to identify the clients plans after exiting the programme, and the support which the client and caregiver would require after discharge.

28 Case workers coordinate discharge for the client by collaborating with the client, and if necessary, family and community care resources. Ideally, a thorough care system should be adopted where the caseworker who assessed the client and who developed the care plan should oversee the discharge. Familiarity with the client will ensure continuity of care, optimal use of resources and the clients existing support


network, as well as responsiveness to the clients preferences and anticipated change in needs. As with developing the care plan, the discharge plan should also be welldocumented.



29 The date and proceeds of the post-discharge review should be indicated in the case notes. Questions to ask the client in order to assess the adequacy and effectiveness of the discharge process include: · · · How are you coping? Do you have any questions? Have you received the services arranged prior to the discharge (for e.g. escort and transport service for medical appointments, home chores/meal services? Is your caregiver able to provide adequate support? What has changed?

· ·


Chapter 6


30 The adoption of standard checklists, templates, forms or letters will ensure clarity and objectivity in assessments, thoroughness in the process and common understanding and interpretation of needs and treatment. The checklist provides guiding questions to ensure standards of care for clients when providers develop care and discharge plans. Below is the suggested list of standard documents which can be applied:(1) (2) (3) (4) Care plan checklist (sample at Annex 2). Discharge plan checklist (sample at Annex 2). Template for care and discharge planning (sample at Annex 3). Letter of consent on disclosure of personal data for emergency and statistical compilation (according to each agencys procedure and practice). Letter of referral to next agency (according to each agencys procedure and practice).




Annex 1 Privacy Concerns - Principles Of Information Sharing Before releasing information, agencies need to consider: 1. 2. 3. 4. Is there a legitimate purpose for you or your agency to share the information? Does the information enable a person to be identified? Is the information confidential? If so, do you have consent to share? Has the client/ clients parent or guardian sign a consent form? Is there a statutory duty or court order to share the information? If consent is refused or there are good reasons not to seek consent, is there sufficient public interest to share the information? If the decision is to share, are you sharing the right information in the right way? Have you properly recorded your decision?

5. 6.



Source: Every Child Matters, Change for Children, "Making it Happen ­ Working Together For Children, Young People And Families ", UK.


Annex 2 Table 1: Care Plan Checklist Care Plan Checklist 1. The clients strengths, needs, abilities and preferences (SNAP) are documented and considered. 2. The client and caregivers are consulted, and their preferences are accommodated (where possible). 3. The plan is appropriate to the clients culture, age, physical status and mental state. 4. There is an interpretive summary. 5. The goals are "SMART" ­ specific, measurable, actionable, realistic and time-bound. 6. The roles of all persons involved to achieve the goals are stated. 7. There is a date set for review, and the care plan modified accordingly. 8. The care plan is dated and signed. Yes No


Table 2: Discharge Plan Checklist Discharge Plan Checklist 1. The clients strengths, needs, abilities and preferences (SNAP) at the point prior to discharge are documented. 2. The gains from participating in the programme, or goals achieved are documented. 3. The likely post-discharge needs and issues are identified and conveyed to client and caregiver, if any. 4. Referral to other agencies for post-discharge needs are made, where necessary. 5. Caregivers are briefed on client needs, and informed with other resources available, including caregiver support groups, respite services and other community resources. 6. Contact details of a staff from the discharging organisation has been given to client and caregiver. 7. A designated staff had been assigned to follow-up with the client and caregiver, within a specified time-frame. 8. Information resources, such as pamphlets of community-based services, health-related information (disease prevention, nutrition or diet, coping skills for caregivers, etc.) had been given to client and caregiver. Yes No


Annex 3 TEMPLATE OF A CARE AND DISCHARGE PLAN Agencies can modify the care plan to suit unique programme needs

Referral Source:

Section 1: Referral Information (E.g. CDC, Hospital, FSC, etc)

External Referral No.: Date of Referral: Name of referrer/ Designation: Contact Numbers (Office, Mobile, Email:) Current Location of Client: Section 2: Client's Particulars Case Reference Name NRIC Contact nos. (Home, Mobile, Email) Address: Religion Gender Date of Receipt:

Preferred Language/Dialect Date of Birth



Section 3: Caregiver's Information Has Primary Caregiver Relationship to client : Yes No


Name of Caregiver/Guardian/ Next of Kin Occupation:


Contact Numbers (Home, Office, Mobile, Email) Nationality

Marital Status

Section 4: Intake Assessment Presenting Problem

Underlying Problem

E.g. Abuse/Neglect; Addiction; Care Arrangement/ Shelter; Caregiving Issues; Elderly Issues; Employment Issues; Family Issues; Financial Issues; Health Issues; Housing Issues; Immigration Issues; Interpersonal Issues; Learning Disability; Marital Issues; Mental Health Issues; Psycho-emotional issues; Sexual Issues; Substance Abuse; Suicide, others.

No. of needs

No. of needs met If accepted

Reason for acceptance & date:

Referred to:

If not accepted Name of Organisation

Name of Receiving Staff/ Designation



Section 5: Needs Assessment (if necessary by a multi-disciplinary team) Date created Review date Name and Designation Staff in charge Other staff involved Functional Assessment

Name and Designation Include ability to perform Activities of Daily Living such as feeding, grooming, bathing, dressing, toileting, mobility; Instrumental Activities of Daily Living (using the telephone, grocery shopping, preparing meals, doing housework and laundry); etc.

Assessed by: (Name & Designation) Date: Educational Background & Career History

Include name of school, level and general academic performance for students. Include highest qualification and work history for adults.

Assessed by: (Name & Designation) Date: Medical History

Include nursing needs, RAF status, place of medical follow up, etc

Assessed by: (Name & Designation) Date: Financial Profile

Include reasons for financial difficulties, for e.g.alcoholism, certified permanently incapacitated; chronic illness; drug addiction; family relationship problems, gambling, imprisonment (prison/DRC); in debt or bankruptcy; irregular/not receiving maintenance; irregular employment; large family; low wages; non-contribution from other wage earners; physical/intellectual disability; poor budgeting; unemployment; others. - Family Means Test Information - Financial Assistance (if any) - Charges and Fees, including transport fees if any.

Assessed by: (Name & Designation) Date:


Section 5: Needs Assessment (continued) Include general assessment for e.g. risk or history of abscondence, Psychological Profile

misconduct, violent behaviour, suicidal attempt, substance abuse, non-substance abuse, medical, others. Include observation of behaviour for e.g. aggression, task, anxiety, repetitive behaviour etc.

Assessed by: (Name & Designation) Date: Social History

Include information of next of kin and caregivers, as well as information on formal and informal support network.

Assessed by: (Name & Designation) Date: Strengths/Abilities

Assessed by: (Name & Designation) Date: Interests (e.g. hobbies)/ Stated or Known Preferences Assessed by: (Name & Designation) Date: Section 6: Interpretive Summary Caseworkers Diagnosis

Assessed by: (Name & Designation) Date:


Section 7: Care Plan Description (Aim) Date set Review Outcome date

Goals and Measures

Goal Type (Longterm/ short-term)

Date set

Review Outcome date





Achieved Partially Achieved Not Achieved Partially Achieved Not Achieved Partially Achieved Not achieved Achieved Partially Achieved Not

Action Plan/Strategies

Progress Notes

Note changes in client needs and circumstances and changes to care plan.


Section 8: Discharge Plan

Include role of client, family, community, other agencies and resources

Date of closure Reason for closure

Initiated by:

Goals achieved

Completion of Goals

Caregiver satisfaction survey Duration of stay (days) Organisation referred for follow-up Staff responsible for follow-up Date of planned followup Name of staff and contact details given to client Clients signature/ Date

Is Survey Conducted; Level of Caregiver Satisfaction/ Comments

Tel: Email:

Case managers signature/ Date Approved by:

(Name, Designation and Signature, Date)



Guides/Manuals 1. A Guidebook on Dementia Day Care Centres, (2002), Ministry of Health, Singapore. CARF Behavioural Health Standards Manual 2006, Commission on Accreditation of Rehabilitation Facilities, United States of America. Guide on Intake and Assessment (2006), National Council of Social Services, Singapore Pal Abhimanyau, Individualised Care Planning Training Manual (2006), Social Service Training Institute, Singapore.




Articles 5. Patrice L. Spath, Is Your Discharge Planning Effective? (2003) Brown-Spath & Associates. Knowing When To Share in ,,Making It Happen, Working Together For Children, Young People And Families. 0F5AF5.pdf




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