Medical Social Work (MSW) services are multi-faceted and assess Home Health patients for many different things. The goal of social work is to provide non-medical services and resources to further a patient’s ability to stay safe in their home and reduce rehospitalization. The social worker collaborates with the nurses and therapists to ensure coordinated care. Social work is not just for the patient but is guided under a holistic approach involving family members, Powers of Attorney, caregivers, and other community case workers.
A typical Social Work assessment looks at basic needs; such as access to food/meals, medicine, transportation, and caregiving. There can be assistance in finding more in-home custodial care or assisted living/adult family home placement. The medical social worker can assist in accessing community resources and/or helping with applications, advocacy, and linkage to other case management. Social work services are individualized for each patient’s needs.
- Assessment of economic factors impacting the patient’s quality of life and care
- Community planning using and assessing resources
- Interventions for caregivers, patients and families
- Counseling and long-term care planning
