Discharge from a hospital does not necessarily indicate a return to health, but, rather, a move from acute care to alternate, lower intensity forms of care. In many countries, efforts to reduce health costs have led to shortened hospital stays and a deliberate shift toward community care. Although there are a variety of services to meet the demand for continuing care, the transition from hospital to community is often problematic. Patients and families report extended waiting times, limited accessibility, inadequate services, unmet needs, poor coordination, insufficient information, and lack of resources (Proctor, Morrow-Howell, Li, & Dore, 2000; Waters, Allsopp, Davidson, & Dennis, 2001). Negotiating the transition between inpatient and community care often requires the assistance of skilled discharge planners, usually social workers or nurses (Holliman, Dziegielewski, & Teare, 2003). In Israel, social workers do most of the discharge planning in acute care hospitals, screening for high-risk patients and intervening with those referred by staff members, particularly complex cases. Discharge planning includes early identification and assessment of patients likely to require services; coordinating the multidisciplinary health care team's discharge-related activities; identifying and coordinating resources necessary for post-hospital care; providing information to patients and families to assist them in selecting and applying for services; and follow-up of discharged patients (Auslander & Soskolne, 1993). In practice, discharge planners' time is spent mainly on assessment and coordination, whereas follow-up is rarely done (Holliman, Dziegielewski, & Datta, 2001).