| (1) The client's strengths, needs, abilities, and preferences (SNAP) at the point prior to discharge are documented. |
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| (2) The gains from goals achieved are documented. |
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| (3) The likely postdischarge needs and issues are identified and conveyed to client and caregiver. |
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| (4) Referral to other agencies for post-discharge needs is made, where necessary. |
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| (5) Caregivers are briefed on client needs, and informed with other resources available, including caregiver support groups, respite services, and other community resources. |
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| (6) Contact details of a staff from the discharging organization have been given to client and caregiver. |
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| (7) Assigned staff and social worker had arranged to follow up with the client and caregiver, within a specified time-frame. |
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| (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. |
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