Medical social workers provide a comprehensive assessment of the patient’s support needs and work in collaboration with the patient, their family, and the patients’ Physician to create an individualized plan of care. This includes coordinating arrangements for home care services among other needs and counseling to make the transition home as seamless as possible. Once the patient is home, medical social workers provide follow-up visits to ensure that patients are adhering to their care plans and can identify and address any problems that may arise. Medical social workers are a patient’s biggest advocate and help maintain open lines of communication between patients and healthcare providers. They can keep them informed of any unique circumstances that may affect the patient’s care. Healthcare teams, medical social workers, patients, and families can work together to navigate and overcome hurdles to create the best possible outcome.
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