Harbor:Social work

Social Work Consultation Guidelines

• Consult Social Work early if you anticipate any issues so they can get things during business hours and get to families before they leave. Consult by placing a social work order in Orchid (documents consult time).
• Refer also to [[1]]
• When discharging Homeless patients but still waiting for Social Work:
  • ED Provider drop house and fill out the Homeless Discharge Form in the depart process (offered a meal, Hep A or COVID vaccines, weather appropriate clothing, outpatient medical and/or mental health resources, prescriptions, etc.)
  • ED RN: discharges and departs patient off the track, places a patient sticker on a paper log at the Router Desk for SW/HTF
  • SW/HTF will assess patient, explore placement opportunities and give resources as available for patient.

1. SW Order Indications

Choose the indication that best fits your clinical need/question. Special instructions are helpful.

Lack of Resources

Those who need help connecting with resources (financial, placement, housing, food, transportation, etc)

• Community resources - food banks, gov benefits
• Disability - how to apply for disability (not for filling out application itself)
• Discharge planning/placement - when a patient needs placement to a facility of lower acuity than an acute care hospital (not to be used if homeless)
• Homeless - for housing/resources. If patient has chronic physical and mental health problems, ask for patient to be signed up for Housing for Health.
• Hospice - still need to place a home-health order (only if going home on hospice, not a care facility)
• [Transportation Needs]
• Crisis/Trauma - SW is consulted automatically for all TTAs. Ask for referral to Violence Prevention program if victim of violent crime (shooting/stabbing, etc)

Poor judgement/Substance Abuse

• Behavioral issues
• EtOH related trauma - SW provides a screening & brief intervention
• Non-compliance
• Poor communication
• Positive toxicology screen - mainly used in peds
• Refusal of treatment
• Substance abuse - SW will provide screening & brief intervention

Psychosocial Support

This category has a lot of overlap with psychiatry.

• Adjustment to illness - for psychosocial assessment by SW, help provide coping skill
• Anxiety
• Crisis/trauma - see above
• Depression
• End-of-life issues - for family or patient, help with GOC discussions
• Family conflict
• Grief/bereavement
• HI
• Mental health - SW can provide more resources than just the DMH list, provide full assessment of patient's financial abilities and other social factors
• New diagnosis - overlaps with Adjustment to Illness
• Poor coping
• SI
• Teenage pregnancy - provide resources & support

Regulatory/Legal Issues

• Adoption
• Advanced directive
• AMA
• Domestic Violence
• Reportable pressure ulcer - Stage 3+ ulcers upon presentation. SW will contact adult protective services (if coming from home) or ombudsman (if coming from a health care facility).
• Suspect child abuse
• Suspect elder/dependent elder abuse
• Unidentified person
  • Harbor: Identifying Jane/John Doe, finding next of kin tips

Other Social Determinants of Health Resources

***WPC program ended 11/30/21.*** However, below are some other available programs addressing social determinates of health:

• Re-entry (released from prison <6 months with medical, mental health, substance abuse, or social needs)

• Medically Complex Transitions of care (includes 3 visits to ED in past year)
  • ORCHID Message/Call/Text Rosario Aliviado - Social Work Supervisor. Please include MRN, pt phone number, and reason for referral.
    • 21x.294.8908. She will respond M-F 9:00-4:30 pm but you can ORCHID message/call/text/email anytime.

• Perinatal (high-risk pregnant mothers - homeless, mental health, substance abuse, domestic violence, no food) 844.376.2627

• Homeless ... social work can help facilitate housing
  • Refer to Social Work
    • Place order in ORCHID
      • Consult to Social Work: reason for referral: homeless

• Disabled and needs disability benefits (SSI)
  • Refer to Social Work
    • Place Order in ORCHID
      • Consult to Social Work: reason for referral: disability benefits

• Mental Health
  • Residential & Bridging Care (transition from mental health institution to community) 213.738.4775
  • Intensive Service Recipients (mental health with 2 or more admissions in year, recent DC from psych hospital) 844.804.5200

2. Transportation home:

Harbor Transportation Needs

3. Patient who are homeless:

a. Homeless Task Force - Business hours, 310-848-3325.

• looking for patients with chronic illness (HTN, diabetes, psych, etc) who have had 2+ visits.
• Put in s/w consult and choose "Homeless" under reason for consult, NOT "Discharge planning/placement".
• If eligible - they will help sign up the patient - however, they may be on a waitlist for days to months.

b. Can be given packet of resources by clerk's station or with SW discussion

4. Patients whom family is no longer able to take care of

Please page social work asap - before family leaves - s/w will work with them to see if:

a. IN HOME SUPPORT SERVICES (IHSS) - Medi-Cal program - can either be started or have hours increased (to help with supervision, cooking, bathing, grocery shopping, other ADLs)

b. other community resources are available

c. consider home health referral

d. if family dumps patient and doesn't respond, s/w may file an adult protective services report

e. if the patient truly needs to be placed, run Interqual, try to transfer/admit to obs/short stay for placement

5. Pt/family not happy with current skilled nursing facility (SNF)

a. generally, this is not an appropriate use of the ED - the family needs to work with the SNF s/w to facilitate transfer to another SNF, exception point c. below

b. if actual abuse, s/w at Harbor can help with ombudsman report

c. APPROPRIATE if pt needs a HIGHER level of care b/c of medical needs - then s/w at Harbor can help

6. Clothing rack / clothing for patients

Nursing and social work have access ('Harbor Rack' outside in ambulance entrance)

7. Patients who need PT/OT for placement

a. Admit patient to obs/short stay for placement and PT/OT evaluation b. In rare circumstances, may need to order PT/OT to be done in the ED.

See Also

• Harbor:Main
• Harbor:Whole person care