Create a Discharge Plan Template to Assist VA Patients & Their Families


Week 7’s Reading: 

Week 7 Hospitals, Primary Care, and Home Health Care Social work’s role in health care has traditionally been in hospital and home health care settings. But, as health care is an ever-evolving practice, social work is evolving with it, and you will now find social workers in primary care clinics. Regardless of the setting, the nature of a social worker’s role always falls back to the profession’s basic principles: utilize a strengths perspective, advocate for patients, help them access needed services, and use a person-in-environment lens when examining patients’ needs (NASW, 2016). The role of the social worker is particularly important for those populations who are oppressed and marginalized in society because research has shown that they experience health care disparities. This means they receive unequal access to quality health care as compared to those populations who are not oppressed and/or marginalized. This is where health care social workers can play a significant role; they advocate for those in need of services and help them navigate the complicated systems of American health care and the insurance industry. Whether social workers are interacting with patients in a hospital, home health setting, or a primary care clinic, the principles by which they approach their jobs will remain the same (NASW, 2016).


A key role a social work role in a medical setting is to critically analyze, monitor, and evaluate intervention and program processes and outcomes. Social workers are knowledgeable about evidence-informed interventions to achieve the goals of clients and constituencies, including individuals, families, groups, organizations, and communities. Upon graduation, you have obtained a job with a local VA hospital

You will work in the surgical unit as a hospital social worker who assesses patients’ needs and creates their discharge plans.

After the first few weeks, you notice that most of your patients tend to discharge home with home health care services. The patients, and their families, often ask the same questions about additional community resources and financial assistance

To increase efficiency, you decide to create a discharge plan template that can be used for patients who discharge home with home health services. You have also decided to include local resources that may benefit patients and their families recognizing the implications of the larger practice context in the assessment process and value the importance of inter-professional collaboration in this process.

  For this assignment, include a brief statement that explains the purpose of the discharge plan.

Demonstrate how you would utilize the discharge plan to negotiate, mediate, and advocate with and on behalf of diverse clients and constituencies and facilitate effective transitions and endings that advance mutually agreed-on goals

Utilize resources that are local to where you live  ((( you can use Central florida ( Orlando Florida Area or Alachua/Gainesville Florida )))))))

Include at least five general health-related resources and five financial resources

Provide a brief description of each resource and how it may be of benefit to patients.

Include any additional information that you believe is warranted, based on this week’s readings and your research .

Support your assignment with at least three scholarly resources. In addition to these specified resources, other appropriate scholarly resources, including seminal articles, may be included.

 Your assignment should demonstrate thoughtful consideration of the ideas and concepts presented in the course and provide new thoughts and insights relating directly to this topic. Your response should reflect scholarly writing and current APA standards. Be sure to adhere to Northcentral University’s Academic Integrity Policy.


Social Work in the Veterans Health Administration (VA) System: Rewards, Challenges, Roles and Interventions

Bouncers, Brokers, and Glue: The Self-described Roles of Social Workers in Urban Hospitals.

Integrated Knowledge Translation: Hospital-based Social Work.

Social Work in a Medical Clinic: The Nature and Course of Referrals to the Social Worker.


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