ABSTRACT
Discharge planning is an integral component of transitional care. Patients need to have their care needs assessed early in the admission to put in place a robust care plan that can meet the medical, functional, and social needs of the patient. The care plan must then be clearly communicated to the next care provider as well as the patient and his caregiver to avoid gaps during transition across different settings and providers. For patients with complex care needs in the community, an intensive form of primary care far beyond what is offered in traditional primary care is needed. This can be achieved by being connected to the health system and resources, additional efforts in providing the care coordination to navigate the health system, and optimising clinical and social care around the patient’s needs.