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SSW:

Complex case

Limited resources

Systematic Barriers

Patient:

Healthcare needs

Social isolation

Housing

Financial insecurity

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Patient issue with low-income, no home, need of post discharge plan, and physical therapy needs.

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Social Service Department

Hammond Housing Authority

Friends

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Alert and oriented

Insurance provider: Medicare

No residency

Staying with friend (support systems)

No equipment needed

No POA

In need of SNF

Friend can help with transportation if needed

Hammond Housing Authority

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Patient was accepted into Brickyard Healthcare in Merrillville, IN. They will be transported through a wheelchair van and continue connections with Hammond Housing Authority for the application process.

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Ecological Systems Theory Model

Crisis Intervention Model

Anti-Oppressive Practice Model

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Systems Theory

Person-in-environment Theory

Anti-Oppressive Practice

Maslow's Hierarchy of Needs

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Patient consent/authority

Decision making

Confidentiality

Advocacy

"Patient dumping"

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Student social worker/patient

Elderly community

Socioeconomic status

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Security and codes

Initial with social services

Evaluations from healthcare providers

Resources

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Collaboration

Communication

Planning

Client-centered care/empathy

Nonjudgemental

Active listening

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Competency 2: Advance Human Rights and Social, Racial, Economic, and Environmental Justice

Competency 3: Engage Anti-Racism, Diversity, Equity, and Inclusion (ADEI) in Practice

Competency 5: Engage in Policy Practice

Competency 6: Engage with Individuals, Families, Groups, Organizations, and Communities

Competency 7: Assess Individuals, Families, Groups, Organizations, and Communities

Competency 8: Intervene with Individuals, Families, Groups, Organizations, and communities

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NASW Code of Ethics, Values, and Principles

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NASW Code of Ethics, Values, and Principles

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Dignity and Worth of the Person - Social workers respect the inherent dignity and worth of the person

Importance of Human Relationships - Social workers recognize the central importance of human relationships

Competence - Social workers practice within their areas of competence and develop and enhance their professional expertise

Service - Social workers' primary goal is to help people in need and to address social problems

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SSW:

Empathy

Problem-solving

Active listening

Cultural competence

Resource Navigation

Patient:

Resilience

Social Support

Financial Access

Open-minded

Kind-hearted

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Friends

Hammond Housing Authority

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Financial counseling

Hammond Housing Authority

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The Patient - directly affected by health needs, housing, and care required for safe discharge.

Hospital employees - time and resources

Friends/Family - assistance with caring needs

Hospital - prolonged hospitalization

Insurance - financial impact

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Housing

Income

Strength and Health

Plan of patient

Family support?

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The client is a 71-year-old male patient at the Munster Community Hospital. Patient has a stay of 7 days for a recent fall that damaged his hand and leg. Patient is currently homeless and in need of a skilled nursing facility to regain strength. Skilled nursing facility will not accept patient unless the patient has a plan for after the stay at the facility. Patient is in contact with an organization that can help with housing, but they would like the patient to focus on getting healthier before accepting his application.