Lesson 1Structured social history: household composition, caregiving roles, financial resources, income and benefitsThis part explain how to get focused social history for discharge planning, covering who dey for house, who go take care, money matters, benefits, and financial stress, all with respect, sensitivity, and cultural understanding.
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 part focus on checking daily activities, instrumental tasks, movement, fall danger, and home access like stairs and bathroom, turning all that into clear advice for tools, services, and watching over 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 part show how social workers collect and understand medical info from the clinical team, like diagnoses, outlook, movement limits, and follow-up, so psychosocial advice match medical reality.
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 part teach how to quick-quick map local community resources for safe discharge, like home care, nursing, meals, transport, volunteer help, and match them to patient needs and who qualify.
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 part cover short cognitive and mental health checks for hospital, bedside talk methods, and how to read results for safety, watching, and sending to 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 statusThis part detail how to check legal papers and coverage for discharge, like power of attorney, advance directives, guardianship, insurance, public benefits, and handle any missing or conflicting things proper.
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 part teach how to map family, friends, neighbors, community links, check who available, who reliable, caregiver load, cultural ways, to build strong support network 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 part look at house stability, physical access, area safety, transport choices, and how dem affect keeping appointments, home care, emergency plans 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 part check medicine knowledge, how complex the regimen, pill sorting, self-giving skills, cost problems, and how social workers team with pharmacists and doctors to cut medicine risks.
Assessing health and medication literacyReviewing regimen complexity and timingEvaluating pillbox and reminder systemsIdentifying cost and insurance barriersCoordinating with pharmacy and prescribers
