The Social Work Department at Wyckoff Heights Medical Center is available to assist patients of all ages and their families with their psychosocial and discharge planning needs. The department is staffed with licensed social workers who work in close collaboration with physicians and other members of the multidisciplinary team to ensure a safe transition from the hospital.

Discharge planning is a process that identifies the needs of the patient for a smooth and safe transition from hospital to home or to another level of care in another facility. Discharge planning can start as early as on the day of admission. The social worker will conduct the assessment for high risk patients to determine the need for post-hospital care, engage the patient and/or families in the development of the plan, and coordinate with outside resources for arranging the services.

The patient and family can also request the social worker for discharge planning through the phone call to the social work department or by speaking with a nurse or physician.

Common situations needing social work services are:

• Placement in another level of care facility (nursing home or rehabilitation)
• Homecare
• Suspected abuse/neglect (child or elderly)
• Undocumented or undomiciled patients
• Victims of crime, disaster, rape, or domestic violence
• Teenage pregnancy, fetal demise, adoption, still birth
• Mental health issues
• Substance abuse
• Urgent concrete services such as shelter, food, clothing, medical equipment, etc.
• Diagnosis-based psychosocial and discharge planning services for cancer, diabetes, CHF, tuberculosis, terminally ill, HIV/AIDS, stroke (CVA/Cerebral Vascular Accident), renal failure, or respiratory failure
• Death and bereavement
• Crisis intervention
• Caregiver’s support

Discharge planning, also known as transition planning, can be very complex and challenging as it requires communication and collaboration between patient, family and/or caregiver, hospital staff, insurance companies, and community service organizations. Therefore, early involvement of the family is highly encouraged.

Counseling, education, advocacy, and referrals to community agencies are provided based on psychosocial and medical needs as well as cultural and religious preferences of the patient. A list of nursing homes and certified home health agencies is available from the social worker for patients identified having the need for homecare or placement.