A bedside reference for mapping next steps after an acute stay. Multiple dispositions, with the supporting care options that pair with each. A different care setting may be needed temporarily when home isn't yet an option.
DOC · DCP-01
Discharge Planning
Rev. May 2026
§ 01
Return to Your Own Home (or a family member's home)
Care brought to the patient's residence
AIndependent
Home — No Support Needed
Patient returns home and resumes prior level of independence. No formal in-home services arranged at discharge. All support needs are self-managed or by family.
SupportSelf-managed / family
BClinical
Home with Skilled Home Care
Skilled Home Care — RN, PT, OT, SLP, HHA, MSW. Infusion, wound care, etc.
Pays(Medical insurance)
CDaily support
Home with Private Duty Home Care (PDHC)
Non-clinical caregiver support for activities of daily living — toileting, personal care, safety, laundry, meals, companionship, and more. Medication setup / management available by RN. Typically 4 hr. to 24 hr. daily care support.
B+CDual SupportClinical + daily
Skilled Home Care+Private Duty Home Care
C+DDual SupportDaily + end of life
Private Duty Home Care+Hospice
DEnd of life · home
Home with Hospice Care
Hospice — Comfort-focused care and symptom management with family support at home.
Pays(Medicare insurance)
§ 02
BridgeSuites — Short-Stay Placements when home isn't an option right now
ADaily support
BridgeSuite with Private Duty Home Care
Short-stay suite paired with private duty caregiver support around the clock. When therapy is not needed — just around-the-clock supervision and support.
01Private Duty Home Care — 24 hr. daily care support (Suite + PDHC: private pay)
BClinical + daily
BridgeSuite with Skilled Home Care & Private Duty Home Care
01Skilled Home Care (Therapy) — RN, PT, OT, SLP, HHA, MSW delivered into the suite. (Insurance pays)
— and —
02Private Duty Home Care — 24 hr. daily care support (Private pay)
CEnd of life · suite
BridgeSuite with Hospice & Private Duty Home Care
01Hospice — Comfort-focused. Symptom management and family support delivered into the suite.
— and —
02Private Duty Home Care — 24 hr. daily care support (Private pay)
§ 03
Skilled Nursing Home (SNF)
Facility-based skilled care · search facilities at medicare.gov
AShort-term
Transitional Care Unit (TCU)
Short-term rehabilitation and recovery before returning to a community setting. Daily / frequent therapy and nursing oversight.
StayDays to a few weeks
BLong-term
Permanent Living — Long-Term Care
A permanent residence within the SNF for individuals who require ongoing 24-hour skilled nursing support.
StayIndefinite / permanent
CEnd of life
Permanent End-of-Life Care — Hospice
Hospice services provided separately by a hospice agency in addition to full care within the SNF setting. Comfort-focused care, symptom management, and family support.
Standalone residential hospice setting for patients whose symptom management or care needs exceed what can be supported at home or in an SNF. Around-the-clock comfort care and family support.
StayTypically less than 30 days
§ 05
Secured Memory Care
Permanent placement needed directly from hospital discharge
Tour required in advance
BridgeSuite at Assisted Living Memory Care Facility
For patients with dementia who require a secured residential environment. Permanent placement, arranged directly from hospital discharge. Facilities with a respite suite available for same-day admissions. This allows families some time to move in furniture while supporting prompt hospital discharges. Tours are required in advance — these suites are reserved for patients seeking immediate placement from the hospital when the intent is long-term residency.
StayPermanent placement (respite suite for same-day admission)
Care & clinician acronyms
RN
Registered Nurse
PT
Physical Therapist
OT
Occupational Therapist
SLP
Speech-Language Pathologist
HHA
Home Health Aide
MSW
Medical Social Worker
Service acronyms
SNF
Skilled Nursing Facility
TCU
Transitional Care Unit (short-term rehab)
PDHC
Private Duty Home Care (non-clinical, hourly)
SHC
Skilled Home Care (clinical / therapy)
MA
Medical Assistance
LTC
Long-Term Care
To make a referral, contact us atBridgeCare Health NetworkTo learn more or check availability, contact us at BridgeCare Health Network.
