Clinical Team Leader: Susan Morris, LCSW-C
Patient Profile (Age Range - Socioeconomic Status)
The medicine / surgery patients, as the hospital population, are culturally diverse. Medicine / surgery patients are adults ranging in age from 19 to 89 years of age. The patient population consists of the insured and uninsured. Many of the patients in medicine are the working poor with some middle class mixed in.
Scope and Complexity of Patient Care Needs
Lack Family Support: Patients often require assistance and or supervision at home.
Homeless: Most have no family support, no income, no jobs, often requiring wound care and placement in an assistant living facility, non-compliant with benefit applications, continuously causing multiple hospital admissions
Inpatient Hospice: Requires family meetings, assistance with decision making, withdrawal of care decisions, supportive counseling, grief/bereavement counseling and working with out side agencies.
Guardianship: Requires hours of investigation to locate family members if any, act as coordinator and facilitator of the guardianship process, work with hospital physicians, attorney and out side agencies, requires a court appearance. This process also requires placement either in assisted living, rehab or a skilled facility.
New Hemodialysis Patient: Requires family meetings, assisting patient/family with selecting an out patient dialysis center and faxing required medical information.
Illegal Immigrants: Patients do not have health insurance coverage, ineligible for most benefits and prescription plans, lack sufficient income, and no family support in the United States of America. Many require the above and placement.
Strategies to Meet Patient Care Needs
- Psychosocial Assessments
- Multidisciplinary Rounds
- Consultation with Interdisciplinary Staff/Patient Plan of Care
- Supportive Counseling, End of Life Counseling, Grief/Bereavement Counseling
- Patient/Family Education
- Weekly Discharge Planning
- Community Referrals
Extent to Which Care Meets Patients' Needs
- Most families are located
- Guardianship obtained (for incompetent patients lacking family support)
- Pharmacy assistance applications (Lovenox/Medbank/Cover White Funds)
- Assisted living placement
- Homeless shelters located
- Family / friend support obtained (in most cases)
Patient Care Providers
- Four full-time Clinical Social Workers
- One part-time Clinical Social Worker
- One part-time Licensed Graduate Social Worker
For patient inquiries or to make an appointment, call 1-800-492-5538.