Kristen Kroener, MSW, LSW Inpatient Social Work Kristen Kroener, MSW, LSW

Discharge Planning Assessment Introduction of Social Work Role and Report Building Advocacy, Empowerment, Resource Coordination & Supportive Counseling Disposition Choice and Discussion of Recommendations: PATIENT & FAMILY Review of medical team, other discipline recommendations and physical therapy evaluation Discuss barriers to home discharge, problem solve & supplement with resources OR refer out Assisted Living, Short Term Skilled Nursing Facility, Private Pay Respite Waiver/ Maximus Protective Services & Area on Aging Meal Delivery Agencies Transportation Agencies Home Health Aide Agencies Drug/ ETOH Outpatient Agencies Adult Daycares Medication Assistance Programs & Coupons Provide Preferred Providers LIST (SNF and HC)

Discharge Planning Assessment Discuss Current Living Arrangement How many levels? Steps? Assist at home? Living Conditions? Support System(s) Identify POA Who will assist post discharge CAREGIVER ASSESSMENT: Do they have any functional, medical, OR cognitive limitations Prior Functional Status Independent-Maximum Assist, DME used, Home Safety Modifications Highest Level of Education Will they understand the discharge instructions and follow-ups? Primary Language, Reading and Writing Literacy, Competence Employment Status High/Low Income, Disabled or going through process, Workers Compensation Claim Financial Resources HRSI, Medicaid, Short/Long Term Disability Substance/ ETOH Screening and Brief Intervention Referral to Agency/ Resource

Daily Rounds: Hand Off COMMUNICATION, IDENTIFY NEEDS & ROLES, HAND OFF TO PROVIDER Case Management Team: RN & SW Research: Ie. PATCH Therapy: PT, OT, Speech, Nutrition Medical Team: Attending, Resident, Specialty, Consultant Palliative Care Navigator Hospital Administration Liaison: Nursing Home, Homecare, DME Outpatient Agencies