Discharge Planning and Social Work Support Services | MedStar Health

In-hospital social work services and discharge planning

Social workers can help you think things through and make arrangements for your special needs both during your stay and after you leave the hospital.

Nurse case managers and social workers are available to assist you and your family to make arrangements for post-hospital care.

The staff can help you arrange for a nursing home or aftercare facility, suggest physical, financial or emotional support services, arrange for visiting nurse, hospice or other home care services, arrange for transportation home from the hospital, refer you to community resources such as counseling or personal or family problems, or help you and your family face the difficulties of terminal illness.

It is wise to begin to plan for any needed post hospital care or services early in your hospital stay to assure a safe and appropriate discharge plan. Also, plans need to be coordinated with your insurance coverage. Not all insurances cover all services.

You can reach a nurse case manager or social worker through the nursing staff on your nursing unit, your physician, or by calling the social work extension at the MedStar Health hospital where you’re staying.

Additional in-hospital social work services include:

  • Psychosocial assessments
  • Referrals to community resources
  • Short-term counseling, crisis intervention, and support groups
  • Explaining and offering support to patients and their families around the epidemiology of their diseases including social and environmental risk factors
  • Assistance to patients in accessing public benefits (TANF, SSI, Medicaid/Medicare, Food Stamps)
  • Assistance to uninsured and underinsured patients in accessing medications and medical equipment
  • Facilitating patient access to hospital/medical appointments by addressing transportation issues and other barriers to care
  • Ongoing tracking and follow up with MedStar Health Home Care/Homecare/Durable Medical Equipment services for complex cases to ensure continuity of care

Social work services at home

MedStar Health Home Care provides comprehensive in-home medical social work services for homebound patients. Our professional social workers will assess the patient’s emotional, environmental, psychological and social needs to ensure home is the safest place to heal.

Medical social workers work closely with each patient’s homecare team to ensure their plan for care will help lead to greater health and independence.

In-home medical social work services

  • In-home assessment to identify limitations, barriers, or safety issues
  • Treatment and observation of patients exhibiting significant social and emotional problems affecting their health status
  • Development and periodic re-evaluation of the physician's plan of care
  • Education and counseling for patients and families
  • Connect patients and families to necessary resources and support in the community
  • Help patients expand and strengthen their network of social support