A self-advocacy checklist for people with disabilities and families

Why Discharge Planning Matters

When you leave a hospital, adult care home, nursing home, or treatment program, you should not go home without a clear plan. 

• North Carolina law  says you have the right to a discharge plan that meets your needs. (NC Gen. Stat. §122C-62)
• Federal law  requires hospitals to give you a discharge planning evaluation. (42 CFR § 482.43)

A Discharge Plan tells you where you will live, how you will get care, and what supports are in place to help you succeed.  

You are the most important person in this plan. Speak up and make sure your needs and choices are heard. 

For children in residential programs (like PRTFs or Level II–IV homes)

Care manager 

• Ask: “Who is my child’s care manager at the LME-MCO?” 
• Example: Maria’s mom made sure the care manager joined the discharge meeting so outpatient therapy was ready before Maria came home.

Paperwork 

• Was the Notice of Admission sent to the LME-MCO within 72 hours? 
• Is there a written Discharge/Transition Plan on file

Planning together 

• Is the Person-Centered Plan (PCP) up-to-date and written with family input? 
• NC law (§122C-3, §122C-60) requires planning to be person-centered and involve natural supports. 

Services after discharge 

• Are “step-down” services in place (like outpatient therapy or therapeutic foster care)? 

Barriers and supports 

• Are barriers (housing, school placement, respite) written down? 
• Is there a plan to address them? 

Timeline 

• Is there a set discharge date and a follow-up meeting already scheduled? 

For adults in facilities (adult care homes, nursing homes, behavioral health hospitals)

Care coordination 

• Has the LME-MCO been notified about your discharge? 
• Is a care coordinator working with you? 

Discharge meeting 

• Did a meeting happen with you, family/supports, and providers? 
• Did you agree on services you will have in the community? 

Continuity of care 

• Is there a plan for housing, transportation, and medication? 
• Example: Sam asked about transportation, and his plan now includes paratransit rides to therapy each week. 

Paperwork 

• Is the discharge summary complete and shared with all providers? 

Follow-up 

• Do you have appointments scheduled with community providers? 
• Are you linked to peer support, case management, or benefits help? 

Self-advocacy tips

• Ask Questions Until You Understand. Don’t leave a meeting confused. 
• Bring Someone You Trust. A family member, friend, or advocate can help you speak up. 
• Write It Down. Keep your discharge plan, list of meds, and provider contacts. 
• Name Your Barriers. If housing, transportation, or school placement is missing—say so! 

What to do if you face barriers

• In a hospital, adult care home, or nursing home call the NC Long-Term Care Ombudsman Program at 1-800-310-9777. Ombudsmen help residents resolve complaints and protect rights. 
• If your LME-MCO is not helping with discharge planning or services:
  Call your LME-MCO Member & Family Call Line (number is on your Medicaid card).
  You can also call the NC Division of Mental Health/DD/SAS Advocacy and Customer Service Line at 919-715-3197. 
• If you believe your rights are being violated call Disability Rights NC at 1-877-235-4210 or visit www.disabilityrightsnc.org. 

Helpful resources

• NC Gen. Stat. Chapter 122C (Mental Health, Developmental Disabilities, and Substance Abuse Act): NC General Assembly Website [https://www.ncleg.gov/Laws/GeneralStatuteSections/Chapter122C]
• NC Medicaid Clinical Policies: [https://medicaid.ncdhhs.gov/providers/clinical-coverage-policies] 
• Federal Discharge Planning Rule (42 CFR §482.43): CMS Regulations 
• NC MH/DD/SUS Customer Service Line: 919-715-3197 
• Mental Health Association of NC Information & Referral Line: 1-800-897-7494 (a non-crisis resource line which provides mental health information.)

Remember: You have the right to a safe, supported discharge. If the system puts up barriers, speak up and reach out for help. 

If you would like more information on programs to support community living, please see our factsheet Programs to Support Community Living.