Over 5 million patients transition from hospitals to skilled nursing facilities each year. Millions of others transition from hospitals to their homes, rehabilitation centers and other care settings. Social workers are central to these transitions. They are tasked with discharge planning and coordinating post-acute care from the early stages of a patient’s hospitalization. Their responsibility often follows patients as they move among different caregiver settings.

Who are Social Workers?

Social workers are professionals committed to improving the welfare of individuals, families, and communities. Many social workers operate in hospitals or other healthcare settings to provide case management, counseling, crisis intervention, care coordination, clinical psychotherapy, research, policy design, and patient education.

Those responsible for case management, discharge planning, and post-acute care supervision have a difficult undertaking. They are required to coordinate many moving parts, most often while harmonizing a large team of professionals. To summarize their job, social workers in case management:

  1. Assess the needs of the patient and ascertain the insurance coverage available.
  2. Coordinate discharge of the patient from the hospital and ensure continuity of care.
  3. Ensure constant and fluid communication among the patient, patient family, and the medical team about the details and expectations of post-hospital care.
  4. Provide emotional support in preparing the patient and family for the transition from hospital to home or other care setting.
  5. Refer and connect the patient to in-home services such as home care, home health care, physical therapy, food delivery, and hospice care.
  6. Arrange post-discharge necessities like transportation, medication delivery, and the provision of medical supplies and equipment.
  7. Help with placement in facilities such as nursing facilities, assisted living homes, rehabilitation centers, and drug treatment programs.
  8. Evaluate the quality of care received by the patient to ensure that clinical outcomes and patient needs are met. This also serves to reduce readmissions for both medical and non-medical reasons.

Challenges Social Workers Face

Discharge planning and care coordination are infinitely more effective when medical personnel (like physicians, physical therapists, nurses, social workers and psychiatrists) form and collaborate in an interdisciplinary team. Collaboration among experts in different care fields promotes the identification of risk and patient need across a full spectrum of wellness. The social worker often takes lead on this care team to manage communications and planning among care providers seamlessly. 

But it’s hard to coordinate a care team when they are most often based in different locations and organizations. Unfortunately, it is common to have infrequent communication among health workers, not enough involvement of the patient and family in the planning process, and a deficiency of attentiveness to the individual and unique need of the patient. This may lead to complications like care gaps, delayed discharge, premature discharge, and absence of adequate arrangements for post-hospital care.

Importance of Overcoming These Challenges

Finding solutions to the challenges of discharge planning is crucial. Why? Because patients and families suffer by lack of proper care coordination. Because these complications and problems result in higher rates of readmission and greater financial burden to the hospital.

With a vision to improve patient care and reduce hospital readmissions, hospitals are now penalized based on their 30-day readmission rates. CMS (Centers for Medicaid and Medicare Services) now reduces payments to IPPS (inpatient prospective payment system) hospitals with excess readmissions. Hospitals are now more incentivized to promote proper discharge planning and care coordination in order to ensure financial stability. Many health systems are looking for communication tools to build relationships with their partners outside of the hospital to ensure complete care. 

The Solution

Social workers need smarter tools to accomplish the demands of achieving better patient care. The Prepared Health platform connects all members of a diverse care team, enabling secure and seamless transitions of patients from hospitals or healthcare facilities to their homes using evidence-based care transition recommendations. The platform also empowers the patient and family by involving them in transitions and care.

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