The unique role of the social worker within the Hospital at Home care delivery team

ABSTRACT

Hospital at Home (HaH) provides acute, hospital-level care at home and post-discharge follow-up. Through a review of 293 HaH admissions conducted by an urban, multidisciplinary HaH program from 2014 to 2017, we find that the social worker is involved in 71% of admissions and plays a crucial role in pre-emergency department discharge home care and safety screening, home intake, follow-up support, and transition of care to primary care providers and community-based services. We describe the social work activities involved in this model of care and present composite case studies for further illustration.

KEYWORDS:

• Hospital at Home
• HaH
• home-based care
• home hospitalization
• psychosocial assessment
• social work

Acknowledgments

We would like to acknowledge Janeen Marshall, MD, Elaine Williams, LMSW, & Christine Hamilton, PhD, for their thoughtful contribution to earlier versions of this manuscript.

Disclosure statement

No relevant disclosures

Declarations

Ethics approval for this retrospective analysis of data was granted by the Icahn School of Meciine at Mount Sinai IRB (approval #17-01092). This approval included a waiver of informed consent for data that were collected for grant reporting and internal program monitoring purposes.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website.

Additional information

Funding

This work was supported by the US Department of Health and Human Services, the Centers for Medicare & Medicaid Services Innovation Award (Grant Number 1C1CMS331334), and the John A. Hartford Foundation.