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Abstract An exploratory study of 57 elderly patients discharged from home health agencies sought to identify how they and their caregivers were prepared for discharge and how they were managing. Data were collected from the home care records and post-discharge interviews with patients and caregivers. Results indicate little evidence of formal discharge planning. However, home care records appear to underreport what home care staff do. On follow-up, over half of the patients had improvement in their health, two-thirds were independent in activities of daily living, and few patients had need of formal services.