Medical Social WorkThe Practical Side of Getting Better

An illness brings more than symptoms. It brings forms, phone calls, money worries, a daughter who is running on no sleep, and questions nobody wants to ask out loud. A medical social worker is the person on the team whose whole job is that side of things.

When your doctor orders home health and you qualify, Original Medicare covers medical social services that are part of your plan of care at no cost to you.

What a social work visit looks like

Mrs. Delgado's daughter Rosa has been sleeping on the couch for three weeks. She has used up her vacation days, her own kids need her, and she has not told anyone she is close to breaking. The social worker sits with both of them in the living room. She listens first. Then she pulls out a folder: a caregiver support program through the county, an adult day program two miles away, a respite option, and a worksheet for the family meeting Rosa has been dreading. Nothing is fixed in one visit. But Rosa is no longer carrying it alone.

Mr. Brooks lives by himself, and his pension does not stretch to the medicines he was just prescribed. His social worker helps him apply for a program that lowers the cost, finds a meal delivery service in his neighborhood, and talks through what he would want if he could no longer live alone, while it is still his choice.

What the medical social worker does

• Listens. To the patient and to the family, about the parts of an illness that are hard to say.
• Connects you with programs. Caregiver support, adult day programs, transportation programs, meal delivery, and help with medicine costs. The social worker helps you find them; the programs are run by others.
• Helps with paperwork and benefits. Applications, forms, and who to call.
• Supports caregivers. Burnout, guilt, and how to share the load with the rest of the family.
• Helps you plan ahead. Advance directives, who speaks for you if you cannot, and what matters most to you.
• Counsels around the grief, fear, and frustration an illness brings, in short visits, and refers you on when more help is needed.
• Works with your nurse and doctor so the practical problems that get in the way of care get solved.

What the first visit looks like

Social work visits are ordered as part of your plan of care, usually after the nurse's first visit, which happens within 24 hours after your doctor or the hospital sends the order. The social worker asks what is weighing on you and your family, and leaves you with a short list of next steps. You get one named coordinator who knows your case. We call before every visit.

When to call

Call 911 if someone is in immediate danger or talking about harming themselves. Call your social worker, nurse, or coordinator when a caregiver is reaching the end of their rope, when a bill or a form is blocking care, when the living situation is no longer safe, or when the family cannot agree on what to do next. These are exactly the calls we want.

What family can do

• Say the hard thing. "I cannot keep doing this" is information the social worker can use.
• Gather the papers. Insurance cards, a medicine list, and any legal documents, in one folder.
• Hold a family meeting. The social worker can help you plan it, or be there.

Cost and who qualifies: with Original Medicare, covered home health is $0 if you qualify, and your doctor decides. See what Medicare covers, who qualifies, and what is not covered.

Our team speaks English, Spanish, Armenian, Russian, and Tagalog. Speak another language? Call (818) 579-4012 and ask whether we have staff who speak it. If we do not have staff who speak your language, we arrange a free interpreter.