Lesson 1Structured social history: household composition, caregiving roles, financial resources, income and benefitsThis lesson explains how to gather a focused social history for discharge planning, covering household members, caregiving duties, income sources, government benefits like pensions or rations, and financial pressures, with sensitivity to cultural norms and respect.
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 assessing daily activities, household tasks, mobility, fall risks, and home setup like stairs or bathrooms, turning findings into specific suggestions for aids, services, and supervision post-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 lesson shows how social workers collect and understand medical details from doctors and nurses, such as diagnoses, medicines, mobility issues, and follow-up needs, ensuring social work plans align with medical realities.
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 scanning of local resources like home nursing, ASHA workers, midday meal schemes, auto-rickshaw services, and NGOs, matching them to patient needs and eligibility criteria.
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 cognitive and mental health checks for hospital settings, bedside talk techniques, and interpreting results to guide safety measures, supervision, and referrals to counsellors.
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 verifying legal papers and benefits like power of attorney, advance directives, Ayushman Bharat coverage, or senior citizen entitlements, handling gaps ethically with family involvement.
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 covers mapping family, neighbours, and community links, checking availability, reliability, caregiver load, and family expectations to form strong, lasting support 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 lesson evaluates home stability, access like stairs, neighbourhood safety, and transport like buses or autos, impacting clinic visits, home care, 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 assesses medicine knowledge, routine complexity, pill boxes, self-giving skills, and costs, working with chemists and doctors to cut risks affordably.
Assessing health and medication literacyReviewing regimen complexity and timingEvaluating pillbox and reminder systemsIdentifying cost and insurance barriersCoordinating with pharmacy and prescribers
