Helping patients navigate through the world of healthcare

Healthcare social workers act as patient advocates, educators, advisors, coordinators of care, and strive to preserve the healthcare and dignity of the communities they serve. Almost 60 years ago, Social Work Month was established to spread awareness regarding the profession, and the holistic support they provide to patients, their families, and caregivers.

Heather White, a social worker at St. Clair Health says, “Social work is a work of heart.” Every case is unique, often difficult, and time sensitive. Social workers make sure their patients receive the right care, in a particular timeframe, with accurate coverage. St. Clair’s team provides exceptional and compassionate care to our patients because patients leave a lasting impression on their hearts.

At St. Clair Health, social workers are available between 7:30 a.m. to 9:00 p.m. to answer patient questions about discharge planning, appropriate resources to access in the community, and how the entire process will work while staying in the hospital. St. Clair has a devoted social work and care team on every unit to help assist their patients during a time they will need it most.

RN care managers and social workers play similar roles in healthcare and have the same goal—upholding individual’s interests and rights and make sure our patients have everything they need when discharged.

Here are several ways St. Clair’s social workers and care managers assist their patients from the time they arrive to the day of their discharge.

 

1. Help build a successful discharge plan.

During a patient’s stay at the hospital, our social workers will monitor their progress and begin building a plan for discharge. Patients and caregivers may have questions concerning medications, follow-up appointments, and additional care. Social workers are present to assist in educating their patients on resources they can utilize, and organizing those next steps of care for each patient to feel confident prior to their day of discharge.

Social workers can:

• Connect patients with community resources that will provide them with basic assistance and resources
• Refer patients to mental and behavioral health counseling services to help with issues like anxiety, depression, and addiction
• Assist with coordinating transportation back home or to the patients next location of care

 

2. Coordinate Post Discharge Steps

A patient’s healing process often takes a long period of time, dedication and organization. St. Clair’s social workers coordinate with the patients and families to determine and finalize a successful discharge plan.

At discharge, social workers assist with placement in a facility that specializes in post-acute care. This may be recommended by a patient’s physician to continue the treatment which will keep a patient healthy and avoid readmission.

Some of the options include:

• Skilled nursing facilities, for short- or long-term rehabilitation
• Acute rehabilitation hospitals, for intensive physical, occupational and speech therapies
• Long term acute care hospitals, for patients with complex medical needs requiring specialized care
• Assisted living homes, for those patients who may need continued assistance with their activities of daily living
• Drug and alcohol rehabilitation centers, for inpatient detox or other levels of care
• Facilities to assist with mental health services, for inpatient and outpatient care

 

3. Ways to afford medication after discharge.

Oftentimes patients are prescribed medications for after they leave the hospital and continue their healing process at home or another facility. St. Clair’s RN care managers work alongside our social workers to understand how they can help our patients and make sure they have everything they need when being discharged.

A patient’s care team will assess the patient’s financial status and potentially help alleviate some medication cost so the prescribed medications are more affordable for that particular patient. In addition, St. Clair Health now has a Walgreens Specialty Pharmacy onsite in the new Dunlap Family Outpatient Center. This collaboration saves patients a stop at the drugstore on their way home and eases the transition from hospital care to their home life—all while reducing the likelihood that they’ll have to come back. Working together, St. Clair and Walgreens ensure that patients have everything they need when they leave the Hospital and follow up to make sure they’re using their medications properly.

 

4. Medical equipment needed to recover.

During a patient’s recovery process, a patient may need some equipment to help with mobility, breathing, or simply monitoring their own health. While a patient’s social worker is building their discharge plan, they collaborate with the care managers to assist one another in meeting all of the patient’s equipment needs.

RN Care Managers can help access the following equipment:

• Walkers, wheelchairs, canes, or crutches
• Hospital beds
• Oxygen machines and accessories
• Commode chairs
• Pressure-reducing beds and mattresses

 

5. Connect patients with other resources in the hospital and in the community.

St. Clair’s social workers coordinate and connect patients to the services they need in the community. When reviewing a patient’s discharge plan, our social workers will have the following resources and information ready and tailored for each individual.

Some resources may include:

• Mental health and substance abuse services
• Food bank resources
• Office of Aging programs
• Private duty home health aide information
• Homeless shelters

 

6. Provide comfort.

A hospital setting can bring many emotions for patients and family members. Regardless of the severity of a patient’s condition, it may be overwhelming and create anxiety.

Social workers are there for patients during this time, and may:

• Answer your questions about your care
• Ensure you understand each step in your care plan
• Provide comfort for your family and answer any questions
• Get in touch with your loved ones to keep them up to date

Healthcare social workers operate in a variety of environments and assume numerous roles in the design, delivery, and evaluation of care. Every year, we have the opportunity to recognize this outstanding group of experts that strive to make patients hospital stay easier and a little less stressful.