When a patient is ready to be discharged, but not ready to go home, hospital social workers work around the clock to plan the next step. They sit with patients and families to review the options – whether it be a skilled nursing facility, inpatient rehabilitation center, substance-use treatment center, psychiatric facility, or homeless shelter – and understand their wishes. Then they may spend days or sometimes weeks on the phone to find a spot, obtain insurance authorization (or if a patient is uninsured or underinsured, connect them with resources), and arrange transportation to the facility.
Since the pandemic, all of those pieces have become more complex, as staffing shortages and infection-control guidelines have forced nursing homes and other facilities to significantly reduce the number of new residents they can accept.
Amid this challenging period, the social workers are the positive force helping discharged patients get into these harder-to-secure placements to ensure the hospital has room to care for more acutely ill patients, said PPMC Social Work Director S. Ashley Edwards, MHA, LSW.
“It’s a very stressful job that takes a special type of person,” Edwards said. “They work really hard to be the patient’s advocate while maintaining the goals of the hospital. I’m very proud of our team.”
Amy L. Bobb, MSW, LSW
What’s the most challenging part of your job right now?
“It’s way above fast-paced at this point. People may not understand all the things we have to do behind the scenes to get a patient out of the hospital. We want to help and not have the patients come back to the hospital, and sometimes that takes a lot of time.”
What’s the best part about working at Presby?
“Even though it can be crazy and stressful, I love it here. My PPMC social workers are at the top of my list – they are all fabulous people to work with and do such a great job.”
Amy B. Kaplan, MSW, LSW
What’s a typical day like?
“A typical day includes assessing my patients’ prior level of functioning and where they’ll be when they’re ready to leave the hospital, what their resources are, what they’ll need for a safe discharge, and how to get them there.”
What should people know about Presby’s Social Work team?
“Our goal is to bring the patient’s humanity to the team as we work with them through the hospitalization. If they feel heard, we have done half the job towards a safe and successful discharge.”