上门服务对话:社会工作

医疗稳定社会工作 

lg游戏 social workers help patients when providers have concerns about a psychosocial stressor and its impact on the patient’s medical or mental health. After completing an in-home visit, a lg游戏 provider may request social work involvement. lg游戏 social workers can connect patients to needed community services, provide brief counseling related to adjustment to illness or a change in functioning level, 并协助临终规划.

地标性的社会工作者进行了一次家庭活动, comprehensive psychosocial assessment to identify the primary non-medical needs and stressors impacting the patient’s health. The social worker also discusses the patient’s strengths, values and supports already in place.

以病人为中心的方法 

The social worker’s assessment results in up to three patient-centered goals that support the patient’s medical stability. Social workers promote patient self-management by assigning reasonable tasks for the patient or family to complete toward goal achievement. There are a variety of psychotherapeutic techniques social workers use to engage the patient and help them make positive change.

社会工作干预通常持续6-8周, including care coordination with the lg游戏 interdisciplinary care team and community resources. Follow-up encounters may be conducted by phone or in the home and may be extended to achieve a patient’s goals.

lg游戏 proactively identifies and addresses problems and needs that would otherwise go unnoticed and unmanaged, making timely additions and adjustments to treatment plans with primary care providers that better support patients and caregivers.

以团队为基础的护理

lg游戏 social workers practice through an evidence-based model called Ambulatory Integration of the Medical and Social (A.I.M.S.). lg游戏 social workers function as part of the interdisciplinary care team. 这个团队定期开会，分享病人信息, and documents patient information in a shared electronic medical management system for optimal care coordination.

lg游戏 social workers are familiar with local community resources and maintain a network of community partners to coordinate quality care for patients. lg游戏 social workers strive not to duplicate available services, 但要评估病人的需求, 利用现有的服务和支持, 通过简短的咨询和教育稳定患者, 并协调额外的资源需求.

虽然每个人的需求和结果是不同的, read an example of a real lg游戏 patient that demonstrates the impact that a lg游戏 social worker can have.

79岁的离异女性，约瑟芬，独自生活. 约瑟芬感到孤立, because she can’t drive and doesn’t want to burden her family to provide transportation.

The lg游戏 social worker receives an urgent referral as Josephine has a depression screen (PHQ9) score of 25, 表明严重的抑郁症. Josephine has a behavioral health history of major depression, 广泛性焦虑障碍, 和失眠. She also has several chronic medical conditions including coronary artery disease, 充血性心力衰竭, 类风湿性关节炎, 2型糖尿病并发症和甲状腺功能减退.

After a social work home visit and a psychosocial assessment is completed, the social worker and patient develop the goals listed below.

• 目标1:增加社交
• 目标2:提高独立性
• 目标3:树立积极的自我形象

社会工作的干预措施:

• Connect the patient to a Friendly Visitor program with the Office on Aging and with church friends.
• Apply for Senior Shared Ride transport and coordinate a “trial run” ride with her daughter-in-law.
• Educate and encourage the patient to practice positive self-talk and affirmations; reinforce use in each telephonic follow-up.

结果:

• Josephine connects to the Friendly Visitor program and reconnects with friends from church.
• Josephine no longer feels dependent on her daughter-in-law. She is confident in navigating the public transit system and can participate in social activities.
• Josephine regularly practices positive self-talk and affirmations and reports that “it really works!”
• Josephine’s most recent depression screen (PHQ9) score is 4.