A system and method for guideline-based discharge planning of a patient from a facility, comprising determining via a processor whether a patient meets predetermined discharge criteria from the facility, generating a first signal indicative of the patient's risk of re-admission to the facility, generating a second signal indicative of a plan for providing care for the patient, generating a third signal indicative of a status of the patient for a post-discharge care report, and generating a fourth signal indicative of instructions to discharge the patient from the facility.