Social Workers Role in Home Care

• Plan for patients’ needs after discharge from hospital
• Referrals to community resources such as:
• Meals on Wheels
• Lifeline
• Community Based Alternatives (CBA)
• Primary Home Care (PHC)
• VA Benefits Aide and Attendant Programs
• Coordinate of public transportation
• Counsel, psychological support, and coping techniques for patients and families
• Plan for long term care
• Evaluate social and economic needs (report living conditions to providers)
• Assistance with advanced directives

Social Workers are available in conjunction with medical necessity services such as physical therapy and or nursing not as a stand alone service.