Lesson 1Structured social history: household composition, caregiving roles, financial resources, income and benefitsThis section explains how to gather a focused social history for discharge planning, covering household members, caregiving duties, income sources, benefits, and money worries, while showing respect, sensitivity, and understanding of cultural differences.
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 covers assessing daily activities, practical tasks, movement, risk of falling, and home access like stairs and bathrooms, turning these into clear suggestions for equipment, services, and help needed at home 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 shows social workers how to collect and understand medical details from the healthcare team, such as diagnoses, outlook, movement restrictions, and follow-up arrangements, to make sure psychosocial advice fits 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 section teaches how to quickly identify local community resources for safe discharge, like home care, nursing visits, meal services, transport options, and volunteer help, matching them to patient needs and what they qualify for.
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 introduces simple cognitive and mental health screening tools for hospital settings, bedside chat techniques, and how to use results to guide safety measures, supervision needs, and referrals for 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 section details checking legal papers and coverage for discharge, including power of attorney, advance directives, guardianship, insurance, and government benefits, and handling any missing documents or issues in an upright way.
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, friends, neighbours, and community links, checking their availability, dependability, load on caregivers, and cultural roles to form strong, lasting 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 looks at home stability, physical access, neighbourhood safety, and transport choices, and how these affect keeping clinic dates, getting home care, and 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 section assesses understanding of medicines, complexity of doses, pill sorting, self-giving skills, and cost issues, with social workers teaming up with pharmacists and doctors to cut medicine-related risks.
Assessing health and medication literacyReviewing regimen complexity and timingEvaluating pillbox and reminder systemsIdentifying cost and insurance barriersCoordinating with pharmacy and prescribers
