Social Work Based Home Care

Social Work based home care takes a macro view of a client’s needs, family relationships, home safety and an array of resources and benefits.  In-home care, Social Workers typically are with a Medicare Agency. They are one of the “Skills” which Medicare covers.

Helpful social worker
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Other skilled professionals are Registered Nurses, Physical, Occupational, and Speech Therapists.  In private duty home care, also known as non-medical it is rarer to have a Social Worker. As is often the case when working with elders, the main focus is on medical issues and health status. This is important as the need for in-home assistance often is due to a health issue. It can be short term, post-surgery, after an accident or longer-term due a degenerative disease. Whether it is a cognitive condition like Alzheimer’s disease or physical like Parkinson disease, A.L.S., M.S. or post-stroke. As Medicare services will send in and cover costs of the medical professionals, it is redundant to also have Nursing services from the private duty company.  Between doctor appointments and medical visits via Medicare, the client’s health needs are being addressed. Therefore, having a Social Worker on staff at a private duty home care company is a big plus.


What do Social Workers Do?

They do many things. This causes people often not to be clear on what their function is. Credentials vary from Bachelor’s (BSW), Master’s (MSW) and Licensed (LCSW). Some are clinical practitioners while others are not. There are Medical Social Workers who work in hospitals, Rehab centers, and Medicare Agencies. They follow the patient during their stay or on service. In the home, they may make one visit or a couple but it is not long term. Social Workers are often identified by where they work and what population they work with. This can be residential treatment, in schools, the Criminal Justice System, and so forth. Those who work primarily with seniors are known as Geriatric Social Workers.

Social workers' signs
Photo by Dan Meyers on Unsplash

And, in-home care they can be available to the client throughout the length of care. With progressive diseases, a client can easily receive home care help for years. The Social Worker will be with them throughout every phase of their condition. As needs change, services will also change. Whichever venue the Social Worker is in, they offer support and knowledge to the client and their family.

Assessing Needs

The initial Assessment for home care starts with the first phone call to the company. Standard identifying information is gathered, description of the person’s medical condition, home situation and very importantly, the reason for seeking in-home care at that time. There should not be a lot of questioning about the person’s finances. Discussing schedules, rates and Long Term Care Insurance should suffice. At the caller’s discretion, an appointment can be set to meet in person. Ideally, this should be at the prospective client’s home.  The in-home interview will explore how the client and family members view the situation. A skilled practitioner will glean a lot from:

* Condition of the home.

*Appearance of the client.

*Interactions between family members, usually the spouse or adult son/daughter.

*Conversation with the client – picking up on any cognitive and memory concerns.

*Review of health issues.

*Viewing how the person walks and transfers, gauging their ability to move independently or how much assistance is required – Activities of Daily Living (ADLs).

Once the client decides to hire a caregiver more information is gathered. Then the paperwork is completed. During the interview the Social Worker is observing, sharing their view of the situation and making recommendations.

*Together they all figure out what type of schedule makes the most sense.

*Schedules change as circumstances change.

*Safety is a primary concern or should be – Fall Prevention.

*Is the client able to move about the home safely? What are the impediments?

*Discerning the person’s independence and the tasks they need help with, and how much assistance is all part of this meeting.

Interventions: Resources and Benefits

After the Assessment is completed, Plan of Care done and a schedule decided upon, the Social Worker shares a wealth of knowledge about Government Benefits and Community Resources.  Because of their unique knowledge and training, the Social Worker is best able to give suggestions and connect the client/family to services they may or may not know about. This is why they are often the coordinator of the care team.  Implicit in their involvement is providing emotional support and advocacy. Examples include:

*Veteran and Medicaid Benefits

*Day programs for Dementia/Alzheimer’s disease

*Support Groups

*Elder Law Attorneys

*Long Term Care Insurance

*Hospice Services

*Medical Supplies and Tech Devices to improve safety, independence and quality of life

*Planning – Different Levels of Care and when to look ahead to future needs.

Social Workers in any setting are trained to assess and offer solutions. Social Work based home care brings experience, knowledge of the aging process, family dynamics, and ways to improve the client’s situation, mood, and outlook together for a positive outcome.