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 NHIF, and financial stressors, while maintaining sensitivity, respect, and cultural humility in Kenyan 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.
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 clinical teams, 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 quickly identify local community resources supporting safe discharge, like home care, community health workers, meal programs from churches, and matatu or boda boda transport, matching them to patient needs.
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 for hospital settings, bedside interviewing techniques common in Kenya, and interpreting findings to inform safety, supervision, and referrals to local counselors.
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 verifying legal documents and coverage for discharge, including powers of attorney, advance directives, NHIF status, and public entitlements, addressing gaps ethically in Kenyan legal contexts.
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 mapping family, neighbours, church groups, and harambee ties, assessing availability, reliability, caregiver burden, and cultural expectations to build sustainable support networks post-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 evaluates housing like mabati homes, physical access, estate safety, and transport like matatus, influencing clinic visits, home care, and emergency plans after discharge in Kenyan settings.
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 assesses medication literacy, regimen complexity, pill boxes, self-administration, and costs at local chemists, collaborating with pharmacists to reduce risks in Kenyan communities.
Assessing health and medication literacyReviewing regimen complexity and timingEvaluating pillbox and reminder systemsIdentifying cost and insurance barriersCoordinating with pharmacy and prescribers
