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The social workers at SBH Health System play a vital role in patient care. Although they serve in many capacities, discharge planning is the social worker’s primary function. Together with the case managers, social workers attend interdisciplinary white board rounds where they discuss patients with complicated medical and social problems who are need of discharge planning.
Discharge planning by SBH social workers involves an initial admission screening process which is helpful in identifying the needs of the patient. The social workers utilize High-Risk criteria, which helps identify the most vulnerable patients. Some of these high-risk factors include homelessness, the need for follow-up care post discharge, suspected abuse or neglect, over 65 living and living alone, over 75, developmentally disabled, unemployed, underinsured or uninsured, multiple readmissions, chronic and/or terminal diagnosis, and impaired ADLs.
Based on the patient’s needs, a discharge plan is created. Discharge plans can include nursing home for short-term or long-term rehabilitation, home care/nursing agency referrals and/or referrals to various services indicated. This is all provided to not only ensure that our patients are discharged in a timely and safe manner, but also to avoid a readmission.