This integrative review of the literature analyzed the research about hospital discharge planning within the historical timeline of public policy changes that affected service utilization. There were 36 articles reviewed that represented a variety of disciplines, nursing (n = 21), social work (n = 6), medicine (n = 5), and sociology (n = 4). The review revealed several interesting findings. Though the family is the first line of defense against problems, little work done has been done that focuses on building partnerships between patients, families, and health care providers. The costs of care drive the health care system; yet costs of interventions were rarely described. Intensive case management of at-risk populations has neither been widely adopted nor is it reimbursed through public funding, even though it has been found to be cost effective.