--- name: coordinating-social-work-needs language: en description: Identifies psychosocial barriers to discharge and coordinates social work interventions. Use when assessing social needs, coordinating community resources, or planning post-discharge support. tags: - coordination - hospital-medicine metadata: author: casemark practice_areas: - Hospital Medicine - Internal Medicine document_types: - Coordination Plan skill_modes: - Coordination --- # Coordinating Social Work Needs Identifies psychosocial barriers to discharge and coordinates social work interventions for hospitalized patients. ## Why This Skill Exists Psychosocial barriers are the leading non-clinical cause of prolonged length of stay and 30-day readmissions. CMS data shows that social determinants of health (SDOH) — housing instability, food insecurity, lack of transportation, inadequate social support, financial hardship, substance use, and mental health conditions — contribute to 40-60% of avoidable readmissions. The Joint Commission requires hospitals to screen for psychosocial needs and CMS Conditions of Participation mandate discharge planning that addresses the patient's post-hospital care environment. Hospitalists are often the first to identify social barriers during daily rounds, but resolution requires coordinated effort between social work, case management, community organizations, and the patient/family. Failure to address psychosocial needs before discharge results in unsafe discharges, immediate ED returns, and regulatory citations. Early identification (within 24 hours of admission) reduces discharge delays by 1-2 days compared to late referrals. --- ## Checkpoint A: Pre-Draft Intake (Mandatory) Before initiating social work coordination, confirm: 1. Has a **psychosocial screening** been completed — PRAPARE, AHC HRSN, or institutional equivalent? *(Default: Check admission screening results)* 2. What **specific social barriers** have been identified? *(Default: Screen for housing, transportation, food, finances, safety, substance use, mental health, caregiver availability)* 3. Does the patient have **insurance coverage** for post-acute services? *(Default: Verify with registration/case management)* 4. Is there a **safe discharge environment** — stable housing, utilities, accessibility? *(Default: Assess or defer to social work evaluation)* 5. Does the patient have an identified **primary caregiver** or support system? *(Default: Ask during rounding)* 6. Are there **safety concerns** — domestic violence, elder abuse, child welfare, self-harm? *(Default: Screen using validated tools; mandatory reporting obligations apply)* 7. Has the patient expressed **concerns about going home**? *(Default: Ask directly during rounds)* 8. What is the patient's **cognitive and functional status** for self-care post-discharge? *(Default: Per PT/OT assessment and nursing evaluation)* ### Documents to Request - Admission psychosocial screening results (PRAPARE or equivalent) - Social work assessment (if already completed) - Case management discharge planning notes - Insurance verification and benefits summary - Prior social work or case management involvement (if readmission) - Psychiatric evaluation or behavioral health notes (if applicable) - Substance use screening results (AUDIT-C, DAST-10) - PT/OT functional assessment --- ## Step 1: Screen for Social Determinants of Health Use the PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences) domains: | Domain | Screening Questions | Red Flags | |--------|-------------------|-----------| | **Housing** | Stable housing? At risk of eviction? Homeless? | Homelessness, shelter stay, eviction notice | | **Food** | Reliable food access? Using food banks? Skipping meals? | Food insecurity affecting medication compliance (e.g., insulin with no food) | | **Transportation** | Can get to follow-up appointments? | No transportation for dialysis, chemotherapy, wound care | | **Utilities** | At risk of losing electricity, water, heat? | Home O2 equipment requires electricity; loss of heat in winter | | **Financial** | Can afford medications? Copays? DME costs? | Choosing between medications and other necessities | | **Safety** | Physical or emotional abuse? Feel safe at home? | Any positive DV/abuse screen — mandatory reporting and safety planning | | **Social support** | Anyone to help after discharge? | Lives alone, no emergency contact, isolated elderly | | **Substance use** | Active use of alcohol, drugs, tobacco? | Active use affecting compliance, safety, or discharge plan | | **Mental health** | Depression, anxiety, suicidal ideation? | PHQ-9 ≥ 10, any suicidal ideation — immediate psychiatric referral | | **Legal** | Immigration status affecting care access? Legal issues? | Undocumented status limiting insurance; incarcerated patient | --- ## Step 2: Prioritize and Refer to Social Work Triage social work referrals by urgency: **Immediate (same-day referral):** - Safety concerns (DV, abuse, neglect, suicidal ideation) - Homelessness with discharge within 48 hours - Guardianship or capacity concerns affecting discharge decision-making - Substance use requiring detox placement or MAT initiation **Urgent (within 24 hours):** - No identified caregiver for patient requiring assistance post-discharge - Insurance barriers to necessary post-acute services - Mental health needs not addressed by current treatment - Financial barriers to medication access **Routine (within 48 hours):** - Community resource connection (food banks, transportation services) - Advance directive completion or healthcare proxy designation - Long-term care planning discussions - Spiritual care or chaplaincy referral --- ## Step 3: Coordinate Specific Interventions **Housing instability:** - Contact hospital-based housing navigator (if available) - Connect with local 211 resources, shelters, transitional housing - For medical respite: identify programs that accept patients needing ongoing medical care post-discharge - Document housing status in discharge planning to prevent unsafe discharge **Medication access:** - Enroll in patient assistance programs (PAPs) through pharmaceutical companies - Apply for 340B program eligibility (FQHC patients) - Use hospital charity care or indigent medication funds - Switch to formulary alternatives or $4 generic programs - Provide starter supplies from hospital pharmacy (bridge until outpatient fills) **Caregiver support:** - Assess caregiver readiness and training needs (wound care, medication management, mobility assistance) - Refer to caregiver support groups and respite care resources - Arrange home health aide services through insurance or waiver programs - Provide caregiver with written instructions and 24-hour callback number **Post-acute care placement:** - SNF: Verify 3-midnight qualifying stay (inpatient only — observation days do not count) - LTACH: Average LOS > 25 days; verify clinical criteria and insurance authorization - Inpatient rehab: Functional criteria (3 hours of therapy daily), CMS compliance group diagnoses - Home health: Homebound status, skilled need, physician certification of plan of care --- ## Step 4: Document Social Work Coordination ``` SOCIAL WORK COORDINATION NOTE Date: [Date] Social barriers identified: 1. [Barrier]: [Status — identified / in progress / resolved] 2. [Barrier]: [Status] 3. [Barrier]: [Status] Interventions: - [Intervention 1]: [Owner — SW, CM, physician] — [Target date] - [Intervention 2]: [Owner] — [Target date] Discharge impact: - Barriers resolved: [List] - Barriers remaining: [List with mitigation plan] - Safe discharge assessment: Ready / Not ready — [Rationale] Follow-up plan: - Community resources connected: [List with contact info] - Outpatient social work referral: [Yes/No] - Follow-up appointments: [List] ``` --- ## Checkpoint B: Post-Draft Alignment (Mandatory) Before clearing a patient for discharge: 1. Have all **identified social barriers** been addressed or mitigated? 2. Is the **discharge environment safe** — housing, utilities, accessibility confirmed? 3. Does the patient have **medication access** — prescriptions filled or plan to fill? 4. Is there an identified **caregiver or support system** for patients who need assistance? 5. Are **mandatory reports** filed for any safety concerns (abuse, neglect)? --- ## Quality Audit - [ ] Psychosocial screening completed within 24 hours of admission - [ ] Social work referral placed within appropriate urgency timeframe - [ ] Housing stability assessed and documented - [ ] Food security screened and addressed - [ ] Transportation to follow-up appointments confirmed - [ ] Medication access plan documented (affordability, pharmacy, starter meds) - [ ] Caregiver identified and trained for post-discharge needs - [ ] Safety screening completed (DV, abuse, neglect, self-harm) - [ ] Mandatory reports filed for positive safety screens - [ ] Community resources connected with specific contact information - [ ] Discharge environment assessed as safe (or documented as unsafe with mitigation) - [ ] Post-discharge follow-up plan includes social work if ongoing needs - [ ] Patient education materials provided in appropriate language and literacy level --- ## Guidelines - Screen for social determinants within 24 hours of admission — late identification creates avoidable discharge delays - Never discharge a patient to homelessness without documented social work evaluation and attempt to arrange alternatives - Mandatory reporting obligations (child abuse, elder abuse, domestic violence) override patient confidentiality preferences — consult hospital legal if uncertain - Medication non-adherence is frequently a cost or access issue, not a compliance issue — ask "Can you afford your medications?" before labeling non-compliance - Use teach-back method with patients and caregivers to confirm understanding of post-discharge plans - Involve interpreters for all social work discussions with non-English-speaking patients — do not use family members as interpreters for sensitive topics - Document social barriers in a way that supports discharge planning but respects patient privacy — avoid stigmatizing language - Follow up on community resource referrals — a referral alone does not constitute resolution of a social barrier