Addressing Psychosocial Barriers to Hospital Discharge: A Social Work Led Model of Care

ABSTRACT

Australian hospitals regularly care for patients who cannot be discharged routinely due to complex psychosocial needs that manifest as barriers to discharge. These long-stay or “stranded” patients are at risk of detrimental health outcomes resulting from their extended stay while also potentially delaying admission for those who need acute care. This article discusses a new social work led model of care developed at an Australian metropolitan hospital that targets long-stay patients with psychosocial barriers to discharge. The model of care, overseen by a specialist social worker and assistant, demonstrates how the social work profession can take leadership within the psychosocial realm to improve both organisational and patient outcomes.

IMPLICATIONS

• Facilitating the timely discharge of hospital patients who no longer require acute care is crucial to optimising their health outcomes.

• Hospital social workers can take leadership of the management of long-stay patients where psychosocial barriers to discharge are present.

澳大利亚医院按常规要照料那些出于复杂的心理社会需要而无法出院的病人。这些“老泡”或“搁浅”病人会因滞留而经受不利健康的风险，它同时也耽搁亟需治疗的患者住进医院。本文讨论了澳大利亚一家市立医院推行的一种新的、由社会工作引导的看护模式。这种模式针对的就是因心理社会障碍而长期滞留医院的病人。由专业社会工作者及助手督导的这种模式说明，社会工作行业可以在心理社会领域改善机构和病人的状况方面起主导作用。

KEYWORDS:

• Hospital Social Work
• Delayed Discharge
• Discharge Barriers

Disclosure Statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Metro North Hospital & Health Services SEED (Support, Explore, Excel, Deliver) Innovation Program.