Facility-to-Home Transition Readiness Scorecard
Evaluate how prepared your family is for a complex transition from hospital, SNF, or rehab to home
Answer 20 questions across five categories to assess how ready your transition plan is. For each question, choose Yes (fully in place), Partial (started but incomplete), or No (not done). When you finish, you'll get a score, a category breakdown, and a gap report with specific action items for every gap.
1 Caregiver Coverage
Is there someone present during every hour that coverage is needed — including weekends, nights, and backup contingencies?
1 Is paid caregiver coverage confirmed (not just planned) for every shift in the first 14 days?
2 Is there a named backup caregiver or agency for each shift, in case the primary aide calls out?
3 If nighttime assistance is needed, is overnight coverage in place?
4 Does the family know exactly who is responsible for coordination during gaps between caregiver shifts?
2 Medical Follow-Through
Are the post-discharge medical tasks actually scheduled and confirmed — not just recommended?
5 Is a PCP follow-up appointment scheduled (with a confirmed date and time) within 7–14 days of discharge?
6 Has medication reconciliation been completed — a line-by-line comparison of pre-admission, in-facility, and discharge medications?
7 Are all specialist referrals from the discharge plan scheduled, with confirmed appointments?
8 Has the home health agency confirmed the first visit date and the services ordered?
3 Environment & Equipment
Is the home physically ready to receive someone with changed mobility, new equipment needs, and a recovery routine?
9 Has all ordered durable medical equipment (hospital bed, walker, commode, oxygen) been delivered and set up?
10 Have home safety modifications been completed — grab bars, pathway clearance, fall hazard removal, adequate lighting?
11 Are supplies stocked for at least 14 days — incontinence products, wound care materials, nutritional supplements, medications?
12 Is the home accessible for the patient’s current mobility level — including the path from the car to the bed, and the bathroom?
4 Coordination Capacity
Does someone have the time, information, and authority to manage the daily logistics of the transition?
13 Is there a single identified person (Primary Contact) responsible for coordinating the overall transition plan?
14 Does the Primary Contact have at least 15–20 hours per week available for coordination tasks during the first 2–4 weeks?
15 Is the transition plan documented in writing — caregiver schedule, medication list, follow-up appointments, provider contacts, escalation protocol?
16 Does more than one person know the full plan — so the transition doesn’t depend on a single person’s availability and memory?
5 Contingency Planning
What happens when the plan breaks — because something always changes in the first two weeks.
17 Is there a documented escalation protocol — what’s routine (log it), what’s concerning (call the Primary Contact), and what’s an emergency (call 911)?
18 If the Primary Contact is unavailable for 48 hours, can someone else step in and manage the plan?
19 Has the family discussed and agreed on criteria for when a readmission or ER visit is warranted — vs. calling the doctor?
20 If home health services are delayed or a caregiver doesn’t show, is there a contingency plan (backup agency, family member on call)?
Your Transition Readiness Score
Breakdown by Category
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