The Role of the Medical Social Worker in Home Health

Article submitted by Sharon K. Weatherhead, MBA (Home Care Coordinator - Nurse on Call). She can be reached at

Mom has just returned home from the hospital after an extended illness. Your neighbor, Mrs. Smith, lives alone and was just discharged home from a rehab facility. Mrs. Jones, the greeter at the supermarket, just returned home after having surgery for a fractured hip. What do all of these people have in common? They will all benefit from receiving a combination of services from a Home Health Agency.

Most people think of Home Health care in terms of nursing and therapy (such as physical therapy and occupational therapy). There is another very important member of the Home Healthcare Team - the Medical Social Worker.

The Medical Social Worker, usually referred to as the MSW, is a key member of the interdisciplinary healthcare team. Although the MSW is not consulted on every case, when they are part of the care plan, their strong desire to improve the lives of others shines through.

The healthcare team understands that people recover from injury and illness much quicker when they are at home. People are more comfortable in familiar surroundings, cared for by family and friends. But what happens when that support system is absent or dysfunctional? This is the time for the MSW to work their magic.

Some of the areas that the MSW will assist the patient and/or the family are:

• Multi-issue counseling
• Personal and family problems
• Coping with life threatening or life limiting diseases
• Inadequate housing
• Needs for indigent medication programs
• Abuse, neglect, and exploitation issues
• Unsafe living conditions
• Unemployment and disability issues
• Psychosocial support
• Referrals for services such as: meals on wheels, oxygen, medical equipment needs

The MSW travels to the client's home based on a referral from the patient's physician or at the request of the nursing case manager. Sometimes, additional needs are not known until the healthcare team members visit the client. At that time, an assessment is made of the client's health needs and home needs. Home Health Agencies strive to take care of the whole patient.

The Home Health Interdisciplinary Team works together to ensure that:

• All the patients needs are met (medical and social)
• A plan of care to address those needs is created with approval of the patients physician
• The highest possible standards of care are met in every discipline
• The patient receives personalized services based on their needs

With a Team approach to Home Healthcare, the patient is at the core of the Plan of Care. The addition of an MSW, when indicated, will help to ensure that the whole patient is cared for - medically and socially.