Lesson 1Structured social history: household composition, caregiving roles, financial resources, income and benefitsThis section describes how to obtain a focused social history relevant to discharge, including household composition, caregiving roles, income, benefits like NHIS, and financial stressors, while maintaining sensitivity, respect, and cultural humility in Ghanaian families.
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 section focuses on assessing activities of daily living, instrumental tasks, mobility, fall risk, and home accessibility like stairs and bathrooms, and translating findings into concrete recommendations for equipment, services, and supervision after discharge in local homes.
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 section outlines how social workers gather and interpret medical information from the clinical team, including diagnoses, prognosis, mobility limits, and follow-up plans at local clinics, to ensure psychosocial recommendations are medically realistic.
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 section explains how to rapidly map local community resources that support safe discharge, including home care, CHPS nursing, meals from local groups, trotro transport, and volunteer services, matching them to patient needs and eligibility.
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 section covers brief cognitive and mental health screening tools suitable for medical settings, bedside interviewing techniques common in Ghanaian wards, and how to interpret findings to inform safety, supervision, and referral for specialised care.
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 section details how to verify legal documents and coverage relevant to discharge, including powers of attorney, advance directives, NHIS status, and public entitlements, and how to address gaps or conflicts ethically in our context.
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 section teaches structured mapping of family, friends, neighbours, church groups, and community ties, assessing availability, reliability, caregiver burden, and cultural expectations to build realistic, sustainable support networks after discharge.
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 section addresses evaluating housing stability, physical access in compound houses, neighbourhood safety, and transport options like trotros, and how these influence appointment adherence, home care access, and emergency planning after 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 section covers assessing medication literacy, regimen complexity, pill organization, self-administration skills, and cost barriers with NHIS, and how social workers collaborate with pharmacists at local chemists to reduce medication-related risk.
Assessing health and medication literacyReviewing regimen complexity and timingEvaluating pillbox and reminder systemsIdentifying cost and insurance barriersCoordinating with pharmacy and prescribers
