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, and financial stressors, while maintaining sensitivity, respect, and cultural humility.
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, and translating findings into concrete recommendations for equipment, services, and supervision after discharge.
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, 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, nursing, meals, transport, and volunteer services, and how to match 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, and how to interpret findings to inform safety, supervision, and referral for specialized 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, guardianship, insurance, and public entitlements, and how to address gaps or conflicts ethically.
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, neighbors, 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, neighborhood safety, and transportation options, and how these factors 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, and how social workers collaborate with pharmacists and prescribers 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
