The Critical Role of Social Workers in Home-Based Primary Care

Abstract

The growing homebound population has many complex biomedical and psychosocial needs and requires a team based approach to care (Smith, Ornstein, Soriano, Muller, & Boal, 2006). The [XX] Visiting Doctors Program (MSVD), a large interdisciplinary home based primary care program in [XX], has a vibrant social work program that is integrated into the routine care of homebound patients. We describe the assessment process used by MSVD social workers, highlight examples of successful social work care, and discuss why social workers’ individualized care plans are essential for keeping patients with chronic illness living safely in the community. Despite barriers to widespread implementation, such social work involvement within similar home based clinical programs is essential in the interdisciplinary care of our most needy patients.

From Discharge Planner to “Concierge”: Recommendations for Hospital Social Work by Clients with Intracerebral Hemorrhage

“…Participants wanted information about resources and eligibility for those resources, responsibilities of medical professionals, and ICH symptoms. Discharge planning services were not solely meeting the needs of most clients and caregivers in this study (Judd & Sheffield, 2010; Reckrey et al, 2014). Therefore, in order to decrease readmissions among clients with ICH, social workers may need time to provide additional support outside of discharge planning, especially related to clients’ emotions and advocacy.…”

“…However, little attention is paid to psychological distress experienced by clients and caregivers specific to discharge planning and making medical decisions. Reckrey and colleagues (2014) found that hospital social workers spent about one-fourth of their time on caregiver coping and other issues that seemed related to easing anxiety during discharge planning, such as assistance in moving. However, other research also found that it is typical for social workers to only have a single session with a client (Gibbons & Plath, 2006).…”

“…Self-proclaimed as bouncers, janitors, glue, firefighters, jugglers, and challengers in focus groups of 65 urban hospital social workers, they reported that they are asked to deal with behavioral problems, clean up messes, organize family meetings, link clients and families with resources, deal with crises, and advocate for clients (Craig & Muskat, 2013). Reviews of medical charts also found that 10% of social work referrals were for caregiving coping issues and 14% of referrals were for other issues, which included, but was not limited to: arranging cleaning of cluttered apartments, coordinating home-based recreational services, assisting moving apartments, and caregiving for pets (Reckrey, et al, 2014). Therefore, about one-fourth of social work referrals were for responsibilities that are not typical to discharge planning, but reflect duties that social workers described as janitorial, glue, and firefighting (Craig & Muskat).…”

“…A review of medical charts in a hospital found that 69% of referrals to social work were for clients’ benefits, home care, and community resources, which are typical discharge planning responsibilities (Reckrey, et al, 2014). Another study found that almost half of 377 hospital social workers spent the majority of their time doing discharge planning (Judd & Sheffield, 2010).…”

“…Since the enactment of ACA, hospital social workers are primarily responsible to conduct discharge planning or planning for the many needs of clients to prepare them for hospital discharge (Peterson, 2012). Hospital social workers are capable to and have held many roles historically including addressing crises, connecting clients with community resources, and addressing psychological distress (Craig & Musket, 2013; Reckrey et al, 2014). The purpose of this qualitative study of an ethnically diverse group of clients with ICH and their caregivers was to assess if hospital social work is meeting their overall needs while inpatient and after discharge.…”