Social Worker Services

Social workers work closely with patients to assess the extent of their needs and help them acquire the services and resources necessary to improve their overall wellbeing. They help to solve problems, establish goals, and achieve outcomes.

There are two primary specialties that rely on medical social workers (MSWs) in the field of home health care: home health and hospice. Both of these roles are vital components of a multidisciplinary care team.

What Does a Home Health Social Worker Do?

Home health care encompasses a range of services that help patients with varying medical needs. Many people who receive home health services have recently transitioned to the home from the hospital. Home care can be prescribed by a doctor for patients with chronic illnesses such as diabetes, heart disease, or COPD, or if they are recovering from a surgery or injury.

The role of a home health social worker varies, depending on the unique needs of a patient. Generally, medical social workers provide patients with:

  • Patient advocacy: An MSW serves as the patient’s most ardent advocate. They help to facilitate communication between patients and healthcare providers. As a patient advocate, a medical social worker communicates the patient’s unique needs to the healthcare team, and alerts them to any specific circumstances that may impact the patient’s care. Together, the patient, family, healthcare team, and medical social worker collaborate to navigate treatment plans, overcome obstacles, and achieve the best outcome possible.
  • Compassionate guidance: It can be overwhelming for patients returning home after an illness or surgical procedure. Medical social workers understand the anxiety and uncertainty that accompanies recovery and they provide emotional support and compassionate care for patients and their families. MSWs educate patients and family members to help them understand and follow medical orders. They also utilize their knowledge and experience in the healthcare system to help patients access available resources to prevent relapses in health and improve the patient’s overall quality of life. This includes connecting patients to community assistance programs and support groups, and educating them about health insurance coverage.
  • Collaborative care: After providing a comprehensive assessment of a patient’s support needs, a medical social worker collaborates with the patient, their healthcare team, and their family to develop a customized discharge plan. These plans include the coordination of meals, transportation, medical equipment, counseling needs, and caregiving services to ensure the transition from the hospital to home is as seamless as possible. MSWs also conduct follow-up visits to identify problems and address them as they arise.

What Does a Home Hospice Social Worker Do?

Home hospice care is for patients who have been given a prognosis of six months or less to live. Rather than curing a life-limiting illness, hospice care is intended to provide the best quality of life for the patient and immediate family members during their remaining time together. Much of hospice work involves pain and symptom management. However, hospice social workers play an important role in helping patients and their families manage emotional issues and necessary logistics that arise near the end of life.

Hospice social workers serve as advocates for patients and their families through this difficult time. They work to honor the patient’s self-determination, end-of-life preferences, and cultural differences. They provide emotional support and assist in decision-making and problem solving. When needed, hospice social workers can guide patients and their families in complex issues such as funeral planning, available state and federal funding programs, medical directives, and finances. Hospice social workers also counsel patients and families through their loss and grief.

Contact Us Today

If you or someone you love is transitioning from the hospital to home, or entering a home hospice program, a medical social worker can help navigate the complexities of the healthcare industry and advocate for your best interests.


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