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143 patients 6E and 6W admission date American Hospital Association Appendix appropriate utilization assess barriers occurred Barriers to Appropriate Berkman and Rehr charge planning community agencies community resources continuity data collection form days of admission discharge planner Discharge Planning form discharge planning process discharge planning program evaluation Exhibit factors home care coordinators home care department home care discharge hospital staff identified inappropriate inservice involved length of stay Medicaid medical staff Medicare ment Need for Discharge ning Number of Occurrences number of patients number of referrals nursing care plans nursing home OCCURRENCES OF BARRIERS Outcome Objective patient and family patient needed patient's discharge patient's medical chart patient's stay patients requiring discharge physi procedures questionnaire referral for discharge requiring discharge planning responsibility role service requested social needs social service social work department social work services social workers specific tion tracheostomy Transfer form University of Michigan utilization review ward clerks written referral