Transitioning from Hospital to Home: Resilience-Enhancing Skills for Health Care Social Workers

Abstract

This chapter describes the social worker’s role in hel** patients and their families make a health care transition from hospital to home by augmenting the resilience-enhancing stress model with case management skills. A practice example of a fictitious patient receiving services from the Rush University Medical Center in Chicago, Illinois, through its Bridge program illustrates how social workers contribute to best practices in transitional care. The practice strategies describe the integration of clinical social work skills from the resilience-enhancing stress model (RESM) with the Bridge Model to ensure that clients have sufficient health care resources and services to support their social functioning and resiliency.

Glossary

Care coordination

The deliberate organization of patient care activities and sharing of information among all participants concerned with a patient’s care to achieve safer and more effective care.

Care transitions

The movements patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

Ecological systems theory

A theoretical that describes the interaction and interdependence of individuals with their surrounding systems; this theory encourages social workers to assess how individuals affect and are affected by such physical, social, political, and cultural systems.

Holistic care

Care that considers all factors in a person’s life—including the environment, family dynamics, culture, and more—when determining a path to care and examining client behavior.

Person-centered care

Care that integrates health care services delivered in a setting and manner that is responsive to individuals and their goals, values, and preferences in a system that empowers patients and providers to make effective care plans together.

Person-in-environment

An individual in the context of his or her environment (e.g., physical, familial, spiritual, social, political, or societal environment).

Resilience

The ability to adapt to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility, and to adjust to external and internal demands.

Social determinants of health

Nonmedical factors that influence health outcomes; the “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems sha** the conditions of daily life” (World Health Organization, 2023, para. 1).

Social needs

“A patient-centered concept that incorporates a person’s perception of his or her own health-related needs” (National Academies of Sciences, Engineering, and Medicine, 2019, p. 28).

Supervision

A relationship between a supervisor and a supervisee in which responsibility and accountability for the development of competence, demeanor, and ethical practice take place.

Transitional care

“A set of actions designed to coordinate continuity of health care as patients transfer between different locations or different levels of care within the same location” (Coleman & Berenson, 2004, p. 533).