The workbook presents a model of care for children with severe medical involvement that features the professional care manager. Three phases in planning for home/community discharge are identified: identification of the candidate for in-home care; identification of specific objectives, service providers, funding sources, etc.; and full implementation of the home care plan. Roles of the parents, primary physician, care manager, interdisciplinary team, and community support services personnel in the transition from hospital to home are examined. A section on planning for discharge and home covers the discharge plan and the home care plan, and includes sample checklists for determining the home's physical facility standards. The final section addresses the organizational system of community resources. (CL)