RT Journal
A1 Mor V, Besdine RW
T1 POlicy options to improve discharge planning and reduce rehospitalization
JF JAMA
JO JAMA
YR 2011
FD January 19
VO 305
IS 3
SP 302
OP 303
DO 10.1001/jama.2010.2006
UL http://dx.doi.org/10.1001/jama.2010.2006
AB 
Frail older patients and their families are generally unprepared for the flurry of activity that occurs during a hospitalization and for how quickly they must decide where to go at discharge. Hospital discharge is not the time to undertake the extended process of long-term care planning and goals clarification. The biggest challenge patients and families face as they decide their discharge destination is to establish realistic goals of care in the absence of coherent information about their prognosis and options. This decision is particularly important because of the weighty implications of their choices.