Lesson 1Structured social history: household composition, caregiving roles, financial resources, income and benefitsDis section tell how fi get focused social history weh matter fi discharge, like who live ina di house, who a care fi dem, income, benefits, an money stress, all wid sensitivity, respect, an 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)Dis section focus pon checkin activities of daily living, instrumental tasks, mobility, fall risk, an home accessibility, an turn dem findings inna concrete recommendations fi equipment, services, an 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)Dis section outline how social workers gather an interpret medical info from di clinical team, like diagnoses, prognosis, mobility limits, an follow-up plans, fi mek sure psychosocial recommendations real wid di medical side.
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 schemesDis section explain how fi quick-quick map local community resources weh support safe discharge, like home care, nursing, meals, transport, an volunteer services, an match dem to patient needs an 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 techniquesDis section cover brief cognitive an mental health screening tools weh fit medical settings, bedside interviewing techniques, an how fi interpret findings fi inform safety, supervision, an referral fi specialist 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 statusDis section detail how fi check legal documents an coverage weh matter fi discharge, like power of attorney, advance directives, guardianship, insurance, an public entitlements, an handle gaps or conflicts ethical.
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’ capacityDis section teach structured mapping of family, friends, neighbors, an community ties, checkin availability, reliability, caregiver burden, an cultural expectations fi build real, 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 optionsDis section tackle evaluatin housing stability, physical access, neighborhood safety, an transportation options, an how dese factors affect appointment adherence, home care access, an 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, affordabilityDis section cover assessin medication literacy, regimen complexity, pill organization, self-administration skills, an cost barriers, an how social workers link wid pharmacists an prescribers fi reduce medication risk.
Assessing health and medication literacyReviewing regimen complexity and timingEvaluating pillbox and reminder systemsIdentifying cost and insurance barriersCoordinating with pharmacy and prescribers
