Discharge planning
It starts on admission, not on the last morning. Check before departure: medication reconciliation with the outdated bottles removed, a follow-up appointment with a date, the equipment delivered and installed, home services arranged and confirmed, transport, and a written plan the person can actually read. Teach the warning signs in concrete terms: which sign, what to do, whom to call, at which number. Ask who will be at home, whether there are stairs, and how they will get their medications. A discharge that fails almost always fails on one of these three points.