Social Service/Discharge Planning

Hill Country Memorial Health System

Fredericksburg, Texas

Originating Department: Quality Management


Title:  Scope of Service

Policy #:

Department:  Social Services/Discharge Planning

Approved: M. Matteson

Effective Date: January 22, 2002

Revised Date:  


View/Print the Social Services Discharge Planning Assessment Form




The Scope of Service of the Social Services and discharge Planning Department is to provide an interdisciplinary process that assists patients and their families in reaching their maximum level of functioning and in developing a feasible post-hospital plan of care.



The Department is staffed by Licensed Nurses and Licensed Clinical Social Workers who assess needs for care during and following hospitalization and link patients and families with appropriate resources.  Social Workers also provide psychological evaluation, patient and family counseling, crisis intervention and referral services.


Patients are seen according to the Screening Criteria attached as well as on referral.  Department oversight is done by the Quality Management Department.



The Discharge Planner and Social Worker offer services Monday through Friday 8:00 a.m. to 4:30 p.m.  There is a Social Worker on-call twenty-four hours a day everyday.



1. All hospitalized patients and their families are eligible for assistance with Discharge Planning and/or Social Services according to their individual needs.


2. The Registered Nurse who admits the patient will perform the initial Discharge Planning Screen as part of the admission history and assessment, which is done within twenty-four hours of the patient's admission.  


3. The Social Worker or Discharge Planner will begin to evaluate discharge needs within twenty four hours of receiving the consult.  


4. The Discharge Planner or Social Worker will interview the patient and if the patient is unable to participate will interview the patient's family.


5. Information regarding diagnosis, home conditions, family support, emotional status and financial status will be collected to identify all patient needs that should be met after discharge.


6. The Discharge Planner will arrange at least twice weekly Discharge Planning meetings.  These meetings will assist in the identification of patient needs, continued evaluation and coordination of services by the multi-disciplinary team.  The team includes nursing, physical therapy, occupational therapy, speech therapy, social services, utilization review, respiratory therapy and home health care.  Information is obtained as needed from the admitting office, dietician, cardiac rehabilitation nurse and pharmacy.  Post discharge care, educational needs and equipment needs will be addressed.  (i.e., colostomy, catheters, wound care, IV therapy, etc.)


7. The proposed Discharge Plans are recorded on the daily census sheet and the persons in attendance at the meetings will be noted.  The meeting records will be kept in a notebook in the Discharge Planning office.


8. The Discharge Planner and/or Social Worker will act as a patient advocate and ensure that each patients Discharge Plans are tailored to their specific needs, and are consistent, as much as possible, with the patients expressed desires.  When the patient is not able or competent to make decisions, the family shall speak for the patient.  When there is a discrepancy or conflict between the patient's and family's desires, patients  shall have priority.  When there is conflict between the patient's and physician's plans, the Discharge Planner or Social Worker will speak to both the patient and doctor to resolve the issue.  Unresolved issues may be referred to the Ethics Committee.


9. The Discharge Planner or Social Worker will solicit input from all staff on the patient's discharge needs, and will ensure that Discharge Planning remains a flexible and dynamic process, and that plans can adapt to the changing needs of the patient.  The evaluation of the patient's likely needs may include home health, hospice, Nursing Home, Rehabilitation Hospital, etc.


10. The Discharge Plans and any re-evaluation or re-assessment of the plans will be documented on the Discharge Planning notes in the medical record.


11. Appropriate referrals will be made to facilitate addressing a patient's post-discharge needs.  This will be documented on the Discharge Planning notes in the medical records.


12. Social Worker evaluations, proposed plans, services provided and all other pertinent information will be documented in the medical record.


13. The quality, appropriateness and adequacy of Discharge Planning and Social Services will continuously be assessed.  This will be accomplished by follow-up phone calls to patients and caregivers, and linkages with home health care, nursing homes and other facilities and agencies.  Discharge outcomes (home health agencies, nursing homes, social worker referrals, etc.) are logged for statistical purposes.


14. In the absence of the Discharge Planner, the Social Worker, Outcomes Coordinator or other licensed nurse will serve as the Discharge Planner.


15. The Discharge Planner and Social Worker shall make available an updated resource list to be used by the patient, hospital staff or physicians.


16. The conditions that require a Social Worker include abuse of children or the elderly, sexual assault, domestic violence, adoption and suicide attempt or threat.


17. The Social Workers and Discharge Planners will maintain their knowledge through attendance of workshops, meetings and review of literature. They will attend appropriate continuing education to maintain their licensure.


18. The Discharge Planners and Social Workers will collaborate with representatives of the hospital administration, the medical staff, nursing and other departments involved in patient care when assessing, planning and implementing Social Services as needed.  


19. Any staff person may make a referral to the Social Worker for consultation.


20. The Discharge Planning Nurse will assist the Outcomes Coordinator with medical record reviews and insurance calls as needed.