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

2. 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)

3. 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

4. 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