How Hospital Social Workers Ease the Transition from Hospital to Home

Discharge planning

After a hospital stay, plans upon being discharged involve careful consideration of the patient’s medical issues and development of a plan of care for that patient’s return home. This critical area is called discharge planning and it arranges the logistics so that the patient can recover safely in the comfort of their own home.

Discharge planners are usually hospital social workers that work with the patient and their family to determine how to make the transition from the hospital to the home as smooth as possible.

Transitioning your loved one from the hospital to home can be a scary time since there is a lot to plan for and consider. This is especially the case when the patient is faced with diminished capacities, even temporarily. However, a discharge planner can help smooth this transition and get your loved one back home safely again.

They do the following:

  • Discuss plans for discharge with the patient and/or their family based on the recommendations of medical professionals treating the patient. The social worker may also visit several times toward the end of the hospital stay in order to ensure the discharge plan is appropriate.
  • Assess the needs of the patient and make necessary referrals to ensure he/she will have access to any medical treatment that may be needed after returning home. This may include arranging in-home nursing, in-home therapies, and/or arranging for necessary medical equipment to be delivered to the home.
  • Provide information on resources  within the community as well as any contact information for any state or federal resources that may be needed to assist with the needs of the patient.
  • Possibly contact insurance companies in order to ensure coverage and may also assist with finding alternate payment options for anything not covered.

Once home, a qualified compassionate caregiver from the David York Agency can provide the extra in-home assistance the patient’s needs. For more information about David York Agency’s home health care services, contact us at 718.376.7755. A free consultation can help you decide what services might be best to provide you and your loved one with the care they need. From geriatric social work to advice on how to deal with a diagnosis, David York Agency can help.

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