A discharge plan is a plan for post-hospitalization care intended to identify an individual’s need for medical and social services and resources available to help prevent re-hospitalization. A discharge plan must involve information and instructions to you and your caregivers, including a list of medications, referrals for other care (for example, skilled nursing facilities or home health agencies), and details about Medicare coverage of post-hospitalization services. The plan should be developed with input from you and your representatives about your preferences and care needs.