Our care delivery goal is to help patients achieve and maintain their maximum level of independence and wellbeing.
Patient education coupled with skilled services,
enable patients to be safe in their homes when no home care is required
Social Worker’s Role In-Home Care
- Plan for patients needs after discharge from hospital
- Referrals to community resources such as
- Meals on Wheels
- Lifeline
- Primary Home Care (PHC)
- Community-Based Alternatives (CBA)
- Coordinate of public transportation
- VA Benefits Aide and Attendant Programs
- Plan for long-term care
- Assistance with advanced directives
- Evaluate social and economic health parameters and needs (report living conditions and environment to providers)
- Social workers Counsel provide psychological support and teach coping techniques for patients and families
Social Workers work as an integrated team with other allied healthcare professionals such as physical therapy and or nursing and not as a stand-alone service.