The posthospital needs and care of patients: implications for discharge planning.

Sixty-nine patients hospitalized for a serious illness and discharged to their own or relative's homes were followed up to learn about patient's posthospital needs; sources of help they received and how well they met these needs; and the extent to which hospital social work targets these needs in the discharge planning process. The patients, who were mostly elderly, had substantial needs for care. The family was the major care provider. Although service provision was limited, the social worker had a pivotal role in linking the patient to community services. This exploratory study points to gaps in the hospital screening and discharge planning process.