Medical Social Work
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Medical social work provides practical support and care coordination to help patients and families navigate resources, planning, and next steps while receiving skilled care at home. The focus is simple: reduce stress, clarify options, and help you move forward with a plan.
Who medical social work can help
Medical social work may be helpful for patients and families who want support with planning, resources, and coordination, such as:
- Planning for a safe transition home after a hospital stay or rehab
- Finding community resources (transportation, meals, caregiver support, equipment resources)
- Coordinating next steps with providers and services involved in the plan of care
- Support for caregivers who need guidance and practical planning
- Advance planning conversations and resource guidance (as appropriate)
Services depend on physician orders and your individualized plan of care. We do not promise specific outcomes.
What medical social work may include
Care coordination & practical planning
- Identify needs, goals, and barriers to safe care at home
- Help organize next steps with your care team (as part of the plan)
- Support discharge follow-through and home planning
- Clarify roles, expectations, and caregiver support needs
Community resources
- Connect to local services and support programs (as available)
- Guidance on transportation and access to appointments
- Caregiver support and respite resource options
- Help identify practical supports for daily living
Emotional support & coping
- Support adjusting to illness or new limitations
- Caregiver stress support and problem-solving
- Short-term coping strategies and check-ins within home health scope
- Referrals to additional support resources when appropriate
Advance planning support
- Discuss preferences and planning needs (as appropriate)
- Help understand common documents and next steps
- Coordinate communication with family/providers when needed
- Resource guidance for longer-term planning
What’s provided depends on physician orders and your plan of care. If something falls outside home health scope, we’ll help point you to the right resource.
What to expect
- Reach out: Call or request a call. We’ll confirm service area and a few basics about needs.
- Clarify priorities: We’ll identify what matters most right now (resources, planning, caregiver support, coordination).
- Build a plan: We’ll help connect resources and coordinate next steps as part of your home health plan of care.
Visits are typically short-term and goal-focused, centered on immediate needs related to your plan of care. Please don’t include sensitive medical details in online forms—we’ll collect the right information securely when we speak.
What to prepare (helpful)
- Your top 1–3 concerns (what feels hardest right now)
- Any discharge paperwork or care instructions (if available)
- A list of current providers and who helps you at home
- Questions about resources, transportation, caregiver help, or planning
- Any documents you want help understanding (bring what you have)
Safety note: If you’re in immediate danger or this is a medical emergency, call 911.
Ready to talk?
Call (725) 322-6968 (Mon–Fri, 9am–5pm PT) or request a call—we’ll respond within 1 business day.
Referral partners: Use the Contact form and write “Referral” in your message.
If this is a medical emergency, call 911.