The Social Work and Discharge Planning Department was established to offer professional intervention to patients or families with personal and/or special problems resulting from hospitalization or illness.  The staff is available to assist with discharge planning and to help relieve anxieties and concerns related to illness, treatment, pregnancy, rehabilitation, and recovery.  The staff functions as a liaison between the patient and community, coordinating referral and use of appropriate community agencies.

The Social Work Staff is able to assist medical and hospital staff in treatment of the patient as a "total person" by clarifying and treating social, emotional, and economic problems.  It is our hope that coordination, cooperation and communication among hospital and medical services will hasten return of the patient to his/her family, job and community.

Areas of Service

• Discharge planning, including assistance related to:
• Admission screening and evaluation of discharge needs
• Coordination of home care planning
• Transportation
• Equipment for the home
• Referral to community agencies/resources
• Nursing home placement
• Clarification of Medicare and Medicaid (relative to application for benefits and available medical coverage).
• Assistance in obtaining financial aid:  referral to Financial Planning and community programs.
• Co-ordinates weekly interdisciplinary patient care conferences on the nursing units.
• Identification of and referral to appropriate community resources for specific patient/family needs, including social, psychological, or economic needs.
• Service to high-risk mothers, including:
  • Counseling/planning, problem-need identification
  • Information/referral for financial aid
  • Referral for follow-up of physical, psychological or social need
  • Adoption, notification to and cooperation with adoption agencies/attorneys.
• Participation as a member of the rehabilitation team; social, emotional and economic assessment and guidance to patient/family; coordination of services with the medical and rehabilitation staff.
• Coordinate weekly Total Joint Pre-Surgery Program to prepare patients for their surgery.
• Psycho-social assessment and counseling with patient/family, particularly regarding oncology, cardiac, stroke, and diabetes. 
• Evaluation of psychiatric patients for psycho-social history, individual and marital therapy for psychiatric in-patients and out-patients.  Participates as member of psychiatric team, coordinating discharge needs.
• Planning for and coordination of admission to Home Hospital Elder Care Unit.
• Assistance in pediatric cases including social history, community information and referral, supportive counseling including cases of suspected child abuse or neglect.
• Assistance in Neonatal unit when parents may be experiencing socio-economic stress and/or other personal anxiety.
• Coordination of Home Hospital's  "Lifeline", a personal emergency response system for the elderly and disabled living in their own homes.
• Available to answer questions and provide information regarding Advanced Directives.