What research says about the ways social workers support older patients leaving hospital and returning to the community

First published online 30 Sep 2022.

Why this study was done

When older people leave the hospital, they often need help to safely return home. Social workers play a key role in this process, known as discharge planning. This study reviewed past research to understand what social workers do to support older patients during this transition — especially in situations where resources are limited.

What the study did

The researchers reviewed six studies from the United States and Canada (published between 1993 and 2014) that focused on how social workers help older adults return home after a hospital stay. They wanted to know:

• What tasks social workers perform
• What challenges they face
• What makes discharge planning effective

What the study found

What social workers do

Social workers help older patients by:

• Assessing their needs and home situation
• Educating patients and families about available services
• Coordinating care with doctors, nurses, and community providers
• Referring patients to home care and support services
• Resolving family conflicts and providing emotional support
• Advocating for patient needs
• Following up after discharge (when possible)

Common challenges

• Short hospital stays leave little time for planning
• Poor communication between hospital staff and community services
• Limited availability of home care services
• Family disagreements or lack of support
• Patients with complex medical or mental health needs
• Pressure to discharge patients quickly to free up hospital beds
• Social workers’ roles being taken over by other staff (role dilution)

What makes discharge planning work well?

• Early and thorough assessments
• Strong collaboration between hospital and community services
• Clear communication with patients and families
• Enough time and resources to plan properly
• Social workers being recognised and supported in their roles

What this means

Social workers are essential in helping older people safely return home after a hospital stay. But they face many challenges, especially when resources are limited. The authors highlight a need for more research on how recent aged care reforms, like the National Prioritisation Queue for home care packages, are affecting hospital discharge planning in Australia.

This study was conducted by:

Dr. Bernadette Dimla, A.Prof. Lynne Parkinson, Adjunct Prof. Denise Wood, Dr. Zalia Powell

To read the full article, visit the journal.