“When Things Are Really Complicated, We Call the Social Worker”: Post-Hip-Fracture Care Transitions for Older People

Abstract

Social workers play a key role in the delivery of interdisciplinary health care. However, in the past decade, concerns have been raised about social work's sustainability and contributions in a changing health care sector. These changes come at a time when older patients are more complex and vulnerable than ever before. In this article, using a strengths-based approach, the authors examine the key contributions made by social workers working with older patients with hip fracture as they strive to achieve successful care transitions. Twenty-five interviews with health care professionals (HCPs) were conducted and then analyzed using an analytical coding framework. Although social workers are vital, they are often underused and overlooked in the care of hip fracture patients. The authors sketch the important contributions that social workers make to care transitions after hip fracture, specifically informational continuity; patient-HCP relational continuity; conflict resolution; mediation among family, patient, and HCP (for example, doctors and nurses); collaboration with family caregivers and community supports; and relocation counseling.

Getting Unstuck: Challenges and Opportunities in Caring for Patients Experiencing Prolonged Hospitalization While Stable for Discharge

“…In many cases, the associated complex care of these patients falls to these other team members, which can add additional strain and stresses. 22 An Opportunity to Lower Costs. Because inpatient care accounts for one-third of all health care spending, 23 identifying how to eliminate wasteful practices is a top priority.…”

‘There was no preamble’: Comparing the Transition from Hospital to Home in Different Care Settings

“…Often mitigating negatively perceived transitions was the patient/caregiver-provider relationship, which speaks to care recipients' and carers' desire to connect with a clinician who is a consistent point person. Having one main contact has been found to be beneficial in supporting patients and families during the transition period by providing continuity of both point person and service (Sims-Gould, Byrne, Hicks, Franke, & Stolee, 2015).…”

The Clarity and Contribution of the Hospital Social Work Role: Observations on its Professional Identity

“…Holding a firm professional identity may be hard while the repertoire of skills demanded of hospital social workers is expanding (Burrows 2018). The range of skills is said to span information and education provision, counselling, mediation, advocacy, negotiating, and arranging support services (Duffy and Healy 2011), assessment, co-ordination and advocacy (McLaughlin 2016), conflict resolution, knowledge of local services, and clarity of communication (Sims-Gould et al 2015). Interestingly, despite Beddoe's (2013) finding that hospital social workers' professional identity is partly formed by their knowledge, few studies appear to have focussed on the content of such knowledge, other than familiarity with local care services.…”

“…However, research undertaken with other professionals suggested that they valued social workers for their commitment to patient care and perceived them as particularly skilled in understanding and responding to the complex problems of patients and families (McLaughlin 2016, Sims-Gould et al 2015, Dobrof, Bussey, and Muzina 2019, although Firn, Preston, and Walshe (2017) recommended that better defined job descriptions allowing for some flexibility would facilitate collaboration and efficiency even further.…”