Lesson 1Structured social history: household composition, caregiving roles, financial resources, income and benefitsThis lesson explains gathering a focused social history for discharge planning, covering household setup, family caregiving duties, income sources, government benefits, and money worries, all done with care, respect, and understanding of Botswana's cultural ways.
Documenting household members and rolesExploring employment and income sourcesReviewing benefits and financial supportsIdentifying caregiving responsibilitiesScreening for financial and housing insecurityLesson 2Functional assessment: ADLs, IADLs, mobility, fall risk, home accessibility (stairs, bathroom)This lesson covers checking daily activities, practical tasks, walking ability, fall dangers, and home access like stairs and bathrooms, turning these into clear advice for tools, help, and watching over after leaving hospital.
Assessing ADLs and IADLs systematicallyScreening gait, balance, and fall riskEvaluating home layout and accessibilityRecommending equipment and home modificationsAligning supports with functional capacityLesson 3Gathering medical and treatment information from clinical teams (diagnoses, medications, mobility limits, follow-up plan)This lesson shows how social workers collect and understand medical details from doctors and nurses, like diagnoses, outlook, movement limits, and next steps, to make sure advice fits the patient's health reality.
Clarifying diagnoses and prognosisUnderstanding treatment and rehab plansIdentifying mobility and activity limitsCoordinating follow-up and appointmentsCommunicating across disciplines effectivelyLesson 4Rapid community resources scan: identifying local home care, community nursing, meal programs, transport schemesThis lesson teaches quick mapping of nearby community helps like home care, clinic nurses, food schemes, transport options, and volunteer groups, matching them to what patients need and can get in Botswana.
Building a quick local resource directoryScreening eligibility and referral criteriaMatching resources to functional care needsCoordinating with community agenciesDocumenting resource plans in the chartLesson 5Cognitive and mental health screening: brief tools and bedside interviewing techniquesThis lesson introduces simple mind and feelings checks for hospital bedsides, talk methods, and reading results to spot safety issues, need for watching, and links to special care services.
Selecting brief cognitive screen toolsObserving behavior and mental statusScreening for depression and anxietyAssessing suicide and self-harm riskReferring to psychiatry and neuropsychologyLesson 6Legal and documentation checks: power of attorney, advanced directives, insurance/entitlement statusThis lesson details checking legal papers and covers for discharge, like power of attorney, advance wishes, guardians, insurance, and public helps, handling missing bits or clashes the right way.
Confirming decision-making capacity statusReviewing powers of attorney and guardianshipClarifying advance directives and code statusChecking insurance and entitlement coverageAddressing missing or conflicting documentsLesson 7Social support mapping: family availability, community ties, frequency of visits, informal caregivers’ capacityThis lesson teaches mapping family, friends, neighbours, and village links, checking if they're ready, steady, not too loaded, and fitting cultural ways to make strong support after going home.
Identifying key family and friend supportsAssessing caregiver capacity and strainExploring community and faith connectionsClarifying expectations and role boundariesPlanning backup supports and contingenciesLesson 8Housing and transport evaluation: stairs, elevators, distance to services, transportation optionsThis lesson looks at home steadiness, getting in and out, area safety, and transport choices, and how they affect clinic visits, home help, and emergency plans post-discharge.
Assessing housing stability and tenancyReviewing stairs, elevators, and entrancesConsidering neighborhood safety and servicesMapping transport and paratransit optionsPlanning for urgent and routine travel needsLesson 9Medication management assessment: literacy, pill organization, ability to self-administer, affordabilityThis lesson checks medicine understanding, plan hardness, pill sorting, self-giving skills, and cost blocks, working with chemists and doctors to cut medicine risks.
Assessing health and medication literacyReviewing regimen complexity and timingEvaluating pillbox and reminder systemsIdentifying cost and insurance barriersCoordinating with pharmacy and prescribers
