Coordinating Social Work Needs

---
name: coordinating-social-work-needs
description: Identifies psychosocial barriers to discharge and coordinates social work interventions. Use when assessing social needs, coordinating community resources, or planning post-discharge support.
tags:
  - coordination
  - hospital-medicine
metadata:
  author: casemark
  practice_areas:
    - Hospital Medicine
    - Internal Medicine
  document_types:
    - Coordination Plan
  skill_modes:
    - Coordination
---

# Coordinating Social Work Needs

Identifies psychosocial barriers to discharge and coordinates social work interventions for hospitalized patients.

## Why This Skill Exists

Psychosocial barriers are the leading non-clinical cause of prolonged length of stay and 30-day readmissions. CMS data shows that social determinants of health (SDOH) — housing instability, food insecurity, lack of transportation, inadequate social support, financial hardship, substance use, and mental health conditions — contribute to 40-60% of avoidable readmissions. The Joint Commission requires hospitals to screen for psychosocial needs and CMS Conditions of Participation mandate discharge planning that addresses the patient's post-hospital care environment.

Hospitalists are often the first to identify social barriers during daily rounds, but resolution requires coordinated effort between social work, case management, community organizations, and the patient/family. Failure to address psychosocial needs before discharge results in unsafe discharges, immediate ED returns, and regulatory citations. Early identification (within 24 hours of admission) reduces discharge delays by 1-2 days compared to late referrals.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

Before initiating social work coordination, confirm:

1. Has a **psychosocial screening** been completed — PRAPARE, AHC HRSN, or institutional equivalent? *(Default: Check admission screening results)*
2. What **specific social barriers** have been identified? *(Default: Screen for housing, transportation, food, finances, safety, substance use, mental health, caregiver availability)*
3. Does the patient have **insurance coverage** for post-acute services? *(Default: Verify with registration/case management)*
4. Is there a **safe discharge environment** — stable housing, utilities, accessibility? *(Default: Assess or defer to social work evaluation)*
5. Does the patient have an identified **primary caregiver** or support system? *(Default: Ask during rounding)*
6. Are there **safety concerns** — domestic violence, elder abuse, child welfare, self-harm? *(Default: Screen using validated tools; mandatory reporting obligations apply)*
7. Has the patient expressed **concerns about going home**? *(Default: Ask directly during rounds)*
8. What is the patient's **cognitive and functional status** for self-care post-discharge? *(Default: Per PT/OT assessment and nursing evaluation)*

### Documents to Request

- Admission psychosocial screening results (PRAPARE or equivalent)
- Social work assessment (if already completed)
- Case management discharge planning notes
- Insurance verification and benefits summary
- Prior social work or case management involvement (if readmission)
- Psychiatric evaluation or behavioral health notes (if applicable)
- Substance use screening results (AUDIT-C, DAST-10)
- PT/OT functional assessment

---

## Step 1: Screen for Social Determinants of Health

Use the PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences) domains:

| Domain | Screening Questions | Red Flags |
|--------|-------------------|-----------|
| **Housing** | Stable housing? At risk of eviction? Homeless? | Homelessness, shelter stay, eviction notice |
| **Food** | Reliable food access? Using food banks? Skipping meals? | Food insecurity affecting medication compliance (e.g., insulin with no food) |
| **Transportation** | Can get to follow-up appointments? | No transportation for dialysis, chemotherapy, wound care |
| **Utilities** | At risk of losing electricity, water, heat? | Home O2 equipment requires electricity; loss of heat in winter |
| **Financial** | Can afford medications? Copays? DME costs? | Choosing between medications and other necessities |
| **Safety** | Physical or emotional abuse? Feel safe at home? | Any positive DV/abuse screen — mandatory reporting and safety planning |
| **Social support** | Anyone to help after discharge? | Lives alone, no emergency contact, isolated elderly |
| **Substance use** | Active use of alcohol, drugs, tobacco? | Active use affecting compliance, safety, or discharge plan |
| **Mental health** | Depression, anxiety, suicidal ideation? | PHQ-9 ≥ 10, any suicidal ideation — immediate psychiatric referral |
| **Legal** | Immigration status affecting care access? Legal issues? | Undocumented status limiting insurance; incarcerated patient |

---

## Step 2: Prioritize and Refer to Social Work

Triage social work referrals by urgency:

**Immediate (same-day referral):**
- Safety concerns (DV, abuse, neglect, suicidal ideation)
- Homelessness with discharge within 48 hours
- Guardianship or capacity concerns affecting discharge decision-making
- Substance use requiring detox placement or MAT initiation

**Urgent (within 24 hours):**
- No identified caregiver for patient requiring assistance post-discharge
- Insurance barriers to necessary post-acute services
- Mental health needs not addressed by current treatment
- Financial barriers to medication access

**Routine (within 48 hours):**
- Community resource connection (food banks, transportation services)
- Advance directive completion or healthcare proxy designation
- Long-term care planning discussions
- Spiritual care or chaplaincy referral

---

## Step 3: Coordinate Specific Interventions

**Housing instability:**
- Contact hospital-based housing navigator (if available)
- Connect with local 211 resources, shelters, transitional housing
- For medical respite: identify programs that accept patients needing ongoing medical care post-discharge
- Document housing status in discharge planning to prevent unsafe discharge

**Medication access:**
- Enroll in patient assistance programs (PAPs) through pharmaceutical companies
- Apply for 340B program eligibility (FQHC patients)
- Use hospital charity care or indigent medication funds
- Switch to formulary alternatives or $4 generic programs
- Provide starter supplies from hospital pharmacy (bridge until outpatient fills)

**Caregiver support:**
- Assess caregiver readiness and training needs (wound care, medication management, mobility assistance)
- Refer to caregiver support groups and respite care resources
- Arrange home health aide services through insurance or waiver programs
- Provide caregiver with written instructions and 24-hour callback number

**Post-acute care placement:**
- SNF: Verify 3-midnight qualifying stay (inpatient only — observation days do not count)
- LTACH: Average LOS > 25 days; verify clinical criteria and insurance authorization
- Inpatient rehab: Functional criteria (3 hours of therapy daily), CMS compliance group diagnoses
- Home health: Homebound status, skilled need, physician certification of plan of care

---

## Step 4: Document Social Work Coordination

```
SOCIAL WORK COORDINATION NOTE

Date: [Date]
Social barriers identified:
1. [Barrier]: [Status — identified / in progress / resolved]
2. [Barrier]: [Status]
3. [Barrier]: [Status]

Interventions:
- [Intervention 1]: [Owner — SW, CM, physician] — [Target date]
- [Intervention 2]: [Owner] — [Target date]

Discharge impact:
- Barriers resolved: [List]
- Barriers remaining: [List with mitigation plan]
- Safe discharge assessment: Ready / Not ready — [Rationale]

Follow-up plan:
- Community resources connected: [List with contact info]
- Outpatient social work referral: [Yes/No]
- Follow-up appointments: [List]
```

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

Before clearing a patient for discharge:

1. Have all **identified social barriers** been addressed or mitigated?
2. Is the **discharge environment safe** — housing, utilities, accessibility confirmed?
3. Does the patient have **medication access** — prescriptions filled or plan to fill?
4. Is there an identified **caregiver or support system** for patients who need assistance?
5. Are **mandatory reports** filed for any safety concerns (abuse, neglect)?

---

## Quality Audit

- [ ] Psychosocial screening completed within 24 hours of admission
- [ ] Social work referral placed within appropriate urgency timeframe
- [ ] Housing stability assessed and documented
- [ ] Food security screened and addressed
- [ ] Transportation to follow-up appointments confirmed
- [ ] Medication access plan documented (affordability, pharmacy, starter meds)
- [ ] Caregiver identified and trained for post-discharge needs
- [ ] Safety screening completed (DV, abuse, neglect, self-harm)
- [ ] Mandatory reports filed for positive safety screens
- [ ] Community resources connected with specific contact information
- [ ] Discharge environment assessed as safe (or documented as unsafe with mitigation)
- [ ] Post-discharge follow-up plan includes social work if ongoing needs
- [ ] Patient education materials provided in appropriate language and literacy level

---

## Guidelines

- Screen for social determinants within 24 hours of admission — late identification creates avoidable discharge delays
- Never discharge a patient to homelessness without documented social work evaluation and attempt to arrange alternatives
- Mandatory reporting obligations (child abuse, elder abuse, domestic violence) override patient confidentiality preferences — consult hospital legal if uncertain
- Medication non-adherence is frequently a cost or access issue, not a compliance issue — ask "Can you afford your medications?" before labeling non-compliance
- Use teach-back method with patients and caregivers to confirm understanding of post-discharge plans
- Involve interpreters for all social work discussions with non-English-speaking patients — do not use family members as interpreters for sensitive topics
- Document social barriers in a way that supports discharge planning but respects patient privacy — avoid stigmatizing language
- Follow up on community resource referrals — a referral alone does not constitute resolution of a social barrier