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Social Work Interventions and Effective Discharge Planning

Paper Type: Free Essay Subject: Social Work
Wordcount: 3709 words Published: 27th Aug 2021

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In Australia, many social workers believe that improving the effectiveness of hospital discharge planning and reducing readmission rates are two important issues that are indispensable in the current medical environment. These two interrelated issues reflect the duality of the solution needs to guarantee the effectiveness of successful discharge of hospital patients and address key problem related to the cost of discharge planning. The social work intervention which contributes to effective discharge planning is evidenced by a social worker’s ability to manage patients’ continuing care needs at hospitals and in community-based health settings without recurring need for acute or emergent care services. Transitional care models with social workers focus on the coordination and continuity of care for high-risk patients such as the elderly and patients with high utilization conditions such as heart failure. However, regardless of their risk status or their post-discharge environment, all of the hospitalized patients require some form of discharge planning from the first day of their hospitalization. Efficient and effective discharge planning of hospital patients requires the support of multi-disciplinary teams to proactively address patients’ discharge requirements. At the same time, as a hospital social worker in the multi-disciplinary team, it is necessary to ensure that patients are ready to discharge when they reach the medical goal.

In this article, I identify three systematic reviews.

Two of them target the elderly group. Hickman et.al (2015) focus on transitional care interventions to enhance the effectiveness of discharge plans for the elderly by conducting comprehensive early discharge plans with elderly patients. Hickman et.al (2015) believe that treatment based on a clear communication strategy can reduce the re-admission rate of the elderly. Meanwhile, improving the responsibility of hospital social workers in the transition model is an important part of improving the health outcomes of the elderly in discharge planning. There are six studies in this systematic review which reported complex intervention and only two of them included social workers in the multi-disciplinary team. By identifying and evaluating different multi-disciplinary team interventions, it is possible to indicate the role of social workers in multi-disciplinary teams and to optimize the discharge of the elderly in emergency care settings. The results show that both teams with social workers have significant benefits in improving the functional status and independence of high-risk elderly people in their daily activities. This also reduced the number of re-admission and emergency visits for the first three months. As a result, the findings of this systematic review are related to my chosen question.

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Preyde and Brassard (2011) conducted a systematic review which explores how to improve the effectiveness of discharge plan for the elderly by synthesizing the medical, physical, psychological and social risk factors associated with the adverse health outcomes of elderly patients at discharge. Although this report has been published for 8 years, I think it is still very useful in 2019. They believe that the current health care system is making older patients who discharged from emergency care facilities sicker. Therefore, the re-admission of elderly patients is very common. However, the re-admission could be one aspect of the adverse outcomes of social work discharge planners. As a result, social worker interventions, such as early identification of risk factors, may ensure a successful transition from hospital to home to increase the effectiveness of the discharge plan.

The last one target the patients with heart failure. Albert (2016) highlighted how health care providers (such as general medical nurses, social workers, psychologists, dieticians, and cardiac rehabilitation staff) can implement transitional care services for patients with heart failure, including providing patients with effective discharge plans to promote knowledge and participate in self-care. The purpose of Albert’s review is to evaluate existing care transition models and identify common themes: maximize the effectiveness of the discharge plans, minimize the number of patients’ rehospitalization, and improve the quality of patients’ life with heart failure. When multi-disciplinary providers, especially social workers, act as liaisons and educators during the transition from hospital to family, they help patients with chronic heart failure prepare for discharge and improve the effectiveness of their discharge plans. There are eight common themes of transitional care described in this systematic review related to patients with heart failure. Meanwhile, the second theme is about the multi-professional teamwork, communication, and collaboration. It points out that effective communication between social workers and patients/family is critical to the transition from hospital to home, and patients sometimes have a sense of conflict, worries and anxiety because the attention from the health care team is suddenly removed. As a result, social work intervention is important to effective discharge planning.



Strengths of findings

Limitations of findings

Multidisciplinary team interventions to optimise health outcomes for older people in acute care settings: a systematic review.

Hickman, L. D

Phillips, J. L

Newton, P. J

Halcomb, E. J

Al Abed, N

Davidson, P. M

This systematic review can improve health outcomes for the elderly in acute care settings by refining social worker roles in multi-disciplinary team and responsibilities within transition models.

This systematic review supports the need for team-based interventions for the elderly in hospital in order to improve care outcomes such as function, independence and activities for daily living.

This systematic review did not gain a clear understanding and description of social work intervention treatment components.

It is difficult to provide detail information within the limitations of a manuscript.

Six studies met the inclusion criteria, and each study was conducted in countries around the world, so this report is extensive.

Six studies met the inclusion criteria and each study was conducted in countries around the world, so this report lacks an analysis of the specific environment in a particular region.

Evidence-based Risk Factors for Adverse Health Outcomes in Older Patients after Discharge Home and Assessment Tools: A Systematic Review.

Preyde, M

Brassard, K

Four discharge assessment tools were located in this systematic review and each of them can be developed by social workers to use in general units in acute care settings.

Social work discharge planners can use an assessment tool to evaluate the comprehensiveness of the tool or evaluate whether the risks of the elderly in hospital can be identified.

Hospital policies on discharge planning may also be enhanced by stipulations regarding discharge assessment tools.

There were some limitations due to the inclusion of only English language, published studies in this systematic review.

If unpublished literature and articles published in a different language were included in this systematic review, it is possible to identify other risk factors associated with adverse health outcomes in the elderly population at discharge.

This systematic review can only reflect the risk factors selected by the original research author. Therefore, there may be some factors that have been neglected so far in the research literature.

A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure.

Albert, N. M

This systematic review provides a self-maintenance and management behaviour for social workers to apply in their daily work.

This systematic review describes and summarizes eight common themes for transitional care in relation to patients with heart failure.

Many research reports in this systematic review did not describe detail social work intervention components or social work skills and background to replicate findings and determine best practices.

Current data are limited to mostly small observational or quasi-experimental studies with mixed results that cannot be applied to general populations.

Similarity amongst systematic reviews

The common purpose of these three systematic reviews is to improve the effectiveness of hospital patients’ discharge plans and reduce the possibility of patients being re-admitted. Preyde, Brassard (2011) and Hickman et.al (2015) think that the elderly are high-risk groups in the hospital environment. They all consider social work as part of a multi-disciplinary team in the hospital. Both of two systematic reviews examined key clinical assessment tools used in each of the different studies and the results showed that a focus on social work interventions can enhance discharge planning. The common factor within all systematic reviews is the need for responsive communication on the care needs of the hospital patients. Additionally, more studies in all three different systematic review reflected that patients have better and more efficient discharge plans when they have a multi-disciplinary team with social workers. Albert (2016) also points out that different multi-disciplinary team members have specific communication roles and the social workers can serve as coordinators to ensure that all checklist items on discharge plans are completed prior to hospital discharge. As a result, all three systematic reviews are in agreement that social work interventions have made contributions to effective discharge planning.

Differences amongst systematic reviews

Differences found amongst systematic review papers is due to the different outcome measures used in their chosen researches such as activities of daily living, emergency department visits at different months after post-discharge, the length of hospitalization, rate of recovery, inappropriate drug standard. Hickman et.al (2015) find that a multi-disciplinary team with social work interventions can better optimise the discharge planning for the elderly in acute care settings. They focus on exploring the outcomes of six different multi-disciplinary teams in six chosen pieces of research. All six pieces of research in their systematic review reported complex interventions with or without social work, including an assessment tailored to the needs of the elderly. Preyde and Brassard (2011) use a variety of assessment tools to help identify the risks that are considered important in the discharge plan. They find that there are very few researches published by the social work profession. In their systematic review, social workers in multi-disciplinary teams were regarded as individuals related to various assessment tools. Therefore, a well-developed assessment tool used by social workers can simplify a patient’s discharge planning process and lead to effective discharge practices. Albert (2016) has a completely different target population compared to the other two systematic reviews. He identified eight common transitional-care themes in heart failure by analysing twenty-three transition programs in published literature. This systematic review pointed out that it is challenging for the patients to consult social worker at follow-up appointments. Early outpatient follow-up is an important point for social workers to keep a connection with patients with heart failure. It allows social workers to do an assessment for a patient’s current status and optimize medical management and discharge planning based on current health conditions. Therefore, social worker intervention can facilitate the schedule of a 7-day follow-up appointment to improve an effective discharge plan.

The limitations of the findings

Although all these three systematic reviews are aimed at high-risk groups in hospitals, Preyde, Brassard (2011) and Hickman et.al (2015) are for the elderly with chronic and complex health care needs, while Albert (2016) is for people with heart failure. The systematic review by Hickman et.al (2015) did not provide a clear understanding and description of social work intervention in multi-disciplinary teams. This systematic review included six pieces of research in different countries or areas across the developed world (Australia, Belgium, Finland, France, Spain and Taiwan), but researches in different regions are based on their local medical conditions and policies. Therefore, when applying the findings of this systematic review, it is necessary to consider in detail whether it meets the conditions and situation of the local hospital. The systematic review by Preyde and Brassard (2011) contains only English and published literature. Unpublished literature and articles published in different languages are not included in this systematic review. Therefore, the elderly population at discharge may also have other risk factors associated with poor health outcomes. In Albert’s systematic review (2016), many pieces of research did not describe detailed social work intervention or social work skills to accurately study results and identify best practices. Meanwhile, the current data is limited to small observations or quasi-experimental studies, and different results cannot apply to the general population.


In addition to the above limitations, these three systematic reviews also bridged some academic gaps. There are very few studies published by the social work profession, so it still leaves a lot of gaps in social work academics. In this era of evidence-based practice, social work professionals must demonstrate evidence of their effective practice. Hickman et.al (2015) raised this point of view that social work interventions can be improved with high-level evidenced-based studies to bridge the gap between the acute care setting and the community. Albert (2016) also mentioned that there are potential gaps when transitioning patients from acute care settings to community and he also pointed out that nurses and social workers play important roles in bridging these potential gaps.

The implications of findings on social work interventions

The hospital social workers in a multi-disciplinary team are central to the process of discharge preparation over the course of hospitalization. All three systematic reviews provide evidence from different perspectives and approaches to demonstrate that social work interventions are effective for discharge planning. Meanwhile, the time and effort invested by social workers in discharge planning activities will generate value for the hospital settings and should be recognized and rewarded.

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The systematic review by Hickman et.al (2015) describes the need to improve the care of the older person in hospitals. In this systematic review, a comprehensive geriatric assessment was seen as a gold standard. Social workers in multi-disciplinary teams can make use of this assessment in practice. To be more specific, the comprehensive geriatric assessment can be used to optimise health outcomes in discharge planning for the elderly in acute care settings. Therefore, the contribution of the social workers in multi-disciplinary teams is necessary, which improved the functional status, readmission rate and mortality of elderly patients. The use of comprehensive geriatric assessment in elderly patients admitted to the emergency department was found to improve survival and improve their effectiveness in discharge. As a result, social workers play a critical role in ensuring the implementation of effective models of care.

A comprehensive assessment tool simplifies the discharge planning process for hospital patients and leads to effective discharge practice. Preyde and Brassard (2011) suggest that social workers can use pre-assessment tools to pre-determine the outcome of problems during discharge planning and enable social workers to prepare for the challenge. By using this assessment tool, social workers in multi-disciplinary teams can assist the patient’s family, develop a care plan for the patient by taking advantage of the patient’s strengths, and tailor a more comprehensive discharge plan to meet the patient’s needs. Social work discharge planners who have used assessment tools can consider the comprehensiveness of the assessment tool and whether the assessment can be used to identify the most common risks. Hospital policies on discharge plans can also be strengthened through the provisions of emission assessment tools. In other words, social workers can improve the effective discharge planning process by identifying protection factors. Therefore, adequate assessment tools will help social workers identify patient’s risks and protective factors. This will enable social workers to identify the resources that hospital patients have visited and the resources needed to ensure successful discharge from the hospital.

In addition to applying a comprehensive assessment tool in discharge planning, social workers are also essential to apply recommended self-care maintenance and management behaviours in their daily work. Albert (2016) thinks that social and community support, including family or other caregivers, can help promote compliance with discharge planning, including follow-up. In hospital settings, any transitional care theme needs to be organized to ensure optimal communication between health care providers. Social work interventions on personal factors, social factors, economic factors, cultural factors and many other factors may affect effective discharge plans. In social work practice, social workers need to provide pre-discharge plans for patients with heart failure, personalized instructions, and their potential impact on survival and quality of life, and ways to control it.

In conclusion, hospital policies regarding discharge plans can be strengthened through regulations on discharge assessment tools. There is an increasing number of pieces of evidence supporting that when hospital patients are discharged from a hospital setting to their home, discharge planners (such as social workers) need to conduct a comprehensive assessment of the risk factors identified in these three systematic reviews. These three systematic reviews show that assessing multiple risk factors is an important consideration in a comprehensive assessment. Additionally, social work researchers may use these three systematic reviews to consider modifying the synthesis tool and testing its sensitivity, specificity, and ease of use in the future to improve the effectiveness of the discharge plan. Policy makers and case managers can also use these three systematic reviews to clarify and promote the role of professional social workers in specific areas.

Further research

Albert (2016) believes that future research needs to focus on the benefits of implementing themes and learn best practices to overcome gaps and differences in the eight care themes in his systematic review. Although more researches are needed to determine the effectiveness of various assessment tools, a comprehensive and effective tool can facilitate emissions practices. Hickman et.al (2015) think that an effective discharge plan can enhance effective patient intervention, delay deterioration, prevent readmission and adverse outcomes, and improve quality of life. In addition, pain, fatigue, fluidity loss and grief often occur in hospital patients. However, very few health care providers help patients to deal with some of the sequelae of their disease. Therefore, Preyde and Brassard (2011) suggested that using the appropriate social work assessment tool can solve some of the problems found during discharge planning.

These three systematic reviews contribute to the current debate about how social workers understand and use evidence of knowledge. However, in this field of research, social workers’ own views are rarely noticed. Therefore, I think that future research should also focus on social workers themselves.


  • Albert, N. M, 2016, A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure. Heart & Lung, vol. 45, no. 2, pp. 100-113.
  • Hickman, L. D, Phillips, J. L, Newton, P. J, Halcomb, E. J, Al Abed, N & Davidson, P. M, 2015, Multidisciplinary team interventions to optimise health outcomes for older people in acute care settings: a systematic review. Archives of gerontology and geriatrics, vol. 61, no. 3, pp. 322-329.
  • Preyde, M & Brassard, K, 2011, Evidence-based risk factors for adverse health outcomes in older patients after discharge home and assessment tools: a systematic review. Journal of evidence-based social work, vol. 8, no. 5, pp. 445-468.


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