Lesson 1Structured social history: household composition, caregiving roles, financial resources, income and benefitsThis part explains how to gather focused social history for discharge planning, covering who lives in the home, caregiving duties, income sources, benefits, and money worries, all with respect, sensitivity, and understanding of local customs.
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 looks at assessing daily activities, instrumental tasks, movement, risk of falling, and home access like stairs and bathrooms, turning findings into clear suggestions for equipment, 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 part shows how social workers collect and understand medical details from the clinical team, such as diagnoses, outlook, movement limits, and follow-up, to make sure psychosocial advice fits 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 teaches quick mapping of local community resources for safe discharge, like home care, nursing, meals, transport, and volunteer help, matching them to patient needs and who qualifies.
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 covers simple cognitive and mental health screening tools for hospital settings, bedside talk techniques, and interpreting results to guide safety, supervision, and specialist referrals.
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 details checking legal papers and coverage for discharge, including power of attorney, advance directives, guardianship, insurance, and public benefits, handling any issues 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 part teaches mapping family, friends, neighbours, and community links, checking availability, reliability, caregiver load, and cultural expectations for strong 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 part covers checking housing stability, physical access, area safety, and transport choices, and how these affect keeping appointments, 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 part assesses medicine knowledge, regimen complexity, pill sorting, self-giving skills, and cost issues, with social workers teaming up 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
