It is the role of the orthopedic social worker to assess the patient at admission and coordinate the needs of the patient at the time of discharge. The social worker will gather information from the physical therapist, the occupational therapist, nursing and the physician regarding the patient's progress post-operatively. The social worker will also ask questions to determine if there is family available to provide assistance at home. This information will be reviewed by the care team to determine the most appropriate setting for the patient's recovery.
If the patient has progressed to a point where they are very close to being independent with ambulation and self care then the patient may return to their own home. Prior to leaving the hospital a home care coordinator will arrange home care as needed. Please see the section on home care for more information.
If the patient is making steady progress in therapy but is not strong enough to return home then the Bayview Transitional Care Unit, or a subacute setting utilized by the insurance carrier, may be an option. The Bayview Unit is located on the fourth floor of the main hospital and is used primarily to maximize a patient's independence prior to returning home. This ensures a smooth transition from the acute hospital to home. If the patient meets admission criteria, the social worker will contact the insurance company for approval. Patients are authorized to stay in this unit as long as they make progress in therapy or have what is defined as a skilled need. This unit is designed for patients needing fourteen days or less to recover.
If the patient's progress is slower and they need a longer course of inpatient therapy then the Johns Hopkins Geriatrics Center (JHGC) may be an option. Located next to the acute hospital, the JHGC offers all levels of care and is designed to work with patients for an extended period of time. The goal of both the acute hospital and the JHGC is to rehabilitate the patient to the point where they may return home to their previous living situation.
There are many subacute and rehabilitation facilities available. If the family prefers to utilize a specific facility outside of the Bayview campus or the insurance company designates a different facility, the social worker is available to facilitate the admission process.
The social worker is also available to meet with families who may need guidance regarding resources that are available within the community. For example, social workers can provide information and referrals for Meals On Wheels, adult day care centers, personal care agencies and numerous other resources, depending on the needs of the patient and family. The social worker is an advocate for the patient and will work to coordinate the discharge in an effective and efficient manner. The social worker is available to begin discharge planning prior to hospitalization based on a pre-admission assessment or a request by the patient or family.
