A Model for Social Work in the Health Care Setting
The material on this page is presented courtesy of the New
York-Presbyterian New York Weill Cornell Center Department of Social Work. It
is presented here as a possible model for utilization of social workers in health
care settings.
The Mission
The mission of the Department of Social Work (at the New York-Presbyterian New
York Weill Cornell Center) is consistent with that of the social work profession
and the hospital. It emphasizes comprehensive patient care by:
1) enabling patients and families to identify and utilize their strengths to
cope with illness and disability
2) assisting them in achieving the most effective and efficient plan for continuity
of care
3) maximizing their use of the medical and psychosocial care they receive and
4) preventing and minimizing negative social and psychological consequences
of illness and hospitalization.
The Hospital Social Worker— An integral member of the Interdisciplinary
Team
Role and Functions:
Psychosocial Assessment:
Bio-psychosocial assessment of the whole person
• Advocacy-advocate for patients needs
• Medical Conditions and their impact
• Social supports
• Family relationships
• Insurance and financial situation
• Emotional strengths and deficits
• Housing and environment
• Life condition prior to hospitalization
• Initial discharge and continuity of care planning
Education:
• Helping patients and families understand the illness
• Educating families on levels of care for continuity of care i.e. acute,
sub- acute, home care
• Treatments: consequences of various treatments/treatment refusal
• Entitlements
• Resources
Roles of team members
• Educating staff around the psychosocial issues and responses of friends
and/or families
• Consultation to providers
• Advance Directives
Counseling:
• Crisis Intervention
• Initial adjustment to admission
• Exploring emotional/social responses to illness and treatment
• Using strengths and coping mechanisms to adjust and manage illness and
treatment
• Understanding of and adjustment to possible role changes
• Problem definition and potential solution
• Diagnosing underlying mental illness
• Appropriate referrals
Communication:
• Communicate with team
• Assist patients and families in talking to one another and to members
of inter-disciplinary team
• Formulating questions
• Interpreting information-separating emotion from fact
• Promoting communication and collaboration among team members
• Assisting team members in recognizing their responses to particular
patients
• Facilitating decision making
Discharge Planning and Continuity of Care:
• Accessing needed services
• Planning for future needs
• Ensuring communication and understanding among participants
• Equipment as needed
• Assessing resources-funds, paying for medications, durable medical equipment
• Follow-up as needed
Advocacy:
• Directly representing patients and their rights in health care
• Championing the rights of patients through direct intervention or empowerment
High Risk Criteria for In-patients
If a patient meets any of the following criteria, they must be assessed by a
social worker.
• 80 years old and over
• Undomiciled/homeless
• Impaired mental status
• Admitted with trauma, secondary to violence such as assault, rape
or elder abuse
• Current drug, alcohol or psychiatric disorder
• Chronic medical conditions or surgical treatment that will significantly
impair functional capacities post-hospitalization (i.e. amputation, CVA, etc.)
• Admissions from a nursing home, assisted living, adult home, community
residence
• Receiving home care services prior to admission
• Evidence of lack of sufficient care in the community upon admission,
i.e. dehydrated, infested, found lying on the floor, etc.
• Inadequate resources to fund post hospital care needs
• Child who has been abused, neglected, or abandoned or suspected victim
of abuse or neglect
• High risk pregnancy/infant
• Failure to thrive, adult or child
• Mothers admitted with no prenatal care
• Mothers aged 18 and younger
• Suspected End Stage Renal Disease or HIV/AIDS