Care and Discharge

Planning
A Guide for Service Providers

Serial No: 032/SDD19/DEC06

Contents
Page
Acknowledgements

Feedback

Foreword

Chapters
1

Introduction

Components Of A Care And Discharge Plan

10

Guiding Principles

12

Workflow

14

The Process

15

Checklists

18

Annexes

19

References

28

Acknowledgements

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

Feedback
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.
http://www.ncss.org.sg/evwo/maintemplatetest.asp?show_page=templates/template_c
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.

Foreword
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)

The programme has written procedures on individual care planning.

(2)

Care plans are tailored individually to meet the unique needs and
preferences of the service user and/or his/her family.

(3)

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)

The programme has written procedures on discharge planning.

(2)

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.

Chapter 1
INTRODUCTION

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.

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.

Chapter 2
COMPONENTS OF CARE AND DISCHARGE PLANNING

11

12

Care planning should include consideration of the following:

(1)

Strengths, Needs, Abilities and Preferences (SNAP) of the client;

(2)

An interpretive summary;

(3)

Specific, Measurable, Achievable, Realistic and Time-bound (SMART)

milestones and outcomes;

(4)

Intervention plans and community partners to achieve goals;

(5)

Transition and discharge plans, including criteria for discharge or

transfer; and,

(6)

Roles of client, family/caregiver, staff, volunteers and others in the

support network (e.g. neighbours).

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;

(2)

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;

(3)

Recommendations for follow-up care or services;

(4)

The potential impact of caregiving on the caregiver, and caregiver

needs, training and resources;

(5)

Community and sources of social support for client and caregivers,

including agencies that provide services such as transportation,

10

equipment maintenance, respite care, home care, job referral and

volunteer services;
(6)

Information resources such as pamphlets, videos, books and websites;

and,

(7)

Contact details (including name of contact person, telephone and email)

of the discharging organisation for information or help.

11

Chapter 3
GUIDING PRINCIPLES

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

Client-centred

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.

Flexibility

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);

12

 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.

13

Chapter 4
WORKFLOW

Intake assessment

Chart 1: Care and Discharge

Planning Process

Admission

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

Discharge

Follow-up
14

Chapter 5

THE PROCESS

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 .

Admission

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.

15

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.

Discharge

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

16

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.

Follow-up

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?

17

Chapter 6

CHECKLISTS

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)

Care plan checklist (sample at Annex 2).

(2)

Discharge plan checklist (sample at Annex 2).

(3)

Template for care and discharge planning (sample at Annex 3).

(4)

Letter of consent on disclosure of personal data for emergency and

statistical compilation (according to each agencys procedure and
practice).

(5)

Letter of referral to next agency (according to each agencys procedure

and practice).

18

Annexes
Annex 1
Privacy Concerns - Principles Of Information Sharing
Before releasing information, agencies need to consider:
1.

Is there a legitimate purpose for you or your agency to share the information?

2.

Does the information enable a person to be identified?

3.

Is the information confidential?

4.

If so, do you have consent to share? Has the client/ clients parent or guardian
sign a consent form?

5.

Is there a statutory duty or court order to share the information?

6.

If consent is refused or there are good reasons not to seek consent, is there
sufficient public interest to share the information?

7.

If the decision is to share, are you sharing the right information in the right
way?

8.

Have you properly recorded your decision?

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

19

Annex 2
Table 1: Care Plan Checklist
Care Plan Checklist
1. The clients strengths, needs, abilities and preferences (SNAP) are
documented and considered.

Yes

No

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.

20

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.

Yes

No

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.

21

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:

Date of Receipt:

Name of referrer/
Designation:
Contact Numbers
(Office, Mobile, Email:)
Current Location of
Client:
Section 2: Clients Particulars
Case Reference
Name
NRIC
Contact nos.
(Home, Mobile, Email)
Address:
Religion

Gender

Preferred
Language/Dialect

Ethnicity

Date of Birth

Age

Section 3: Caregivers Information

Has Primary Caregiver
Relationship to client :
Yes
No

22

Name of
Caregiver/Guardian/
Next of Kin
Occupation:

Address

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

Marital
Status

Section 4: Intake Assessment

Presenting Problem

Underlying Problem

No. of needs

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
met
If accepted

Reason for acceptance &

date:

Referred to:

If not accepted
Name of Organisation

Name of Receiving Staff/

Designation

23

Remarks

Section 5: Needs Assessment (if necessary by a multi-disciplinary team)

Date created
Review
date
Name and Designation
Staff in charge
Other staff involved

Name and Designation

Functional Assessment

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:

24

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:

25

Section 7: Care Plan

Description (Aim)

Goals and Measures

Goal Type
(Longterm/
short-term)

Date
set

Review Outcome
date

Date
set

Review Outcome
date

1.

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

2.

3.

4.

Action Plan/Strategies

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

26

Section 8: Discharge Plan

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

Date of closure

Initiated by:

Reason for closure

Goals achieved

Completion of Goals

Caregiver satisfaction
survey

Is Survey Conducted; Level of Caregiver Satisfaction/ Comments

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

Tel:
Email:

Clients signature/ Date

Case managers
signature/ Date
Approved by:
(Name, Designation and Signature, Date)

27

References
Guides/Manuals
1.

A Guidebook on Dementia Day Care Centres, (2002), Ministry of Health,

Singapore.

2.

CARF Behavioural Health Standards Manual 2006, Commission on

Accreditation of Rehabilitation Facilities, United States of America.

3.

Guide on Intake and Assessment (2006), National Council of Social Services,

Singapore

4.

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. http://www.brownspath.com/original_articles/displan.htm

6.

Knowing When To Share in Making It Happen, Working Together For

Children, Young People And Families.
http://www.everychildmatters.gov.uk/_files/59881E141B8023DD062CB83E19
0F5AF5.pdf

28