Development of Processes and Procedures in a Hospital Social Work. Department and Evaluation of their Impact across the Healthcare Continuum

In a tertiary hospital, social workers provide frontline services to all hospital departments and to patients with all kinds of social pathologies. This wide range of activity is challenging and demanding. In order to facilitate and improve functionality of the team by managing patient flow, in 2012 we designed and implemented a stratetgy of generic social work processes and specific procedures. First, we studied the route patients follow in the hospital in order to design the generic process. We listed all the procedures needed and defined a series of operative, strategic, administrative and support resources, both external and internal, linked to the processes and procedures. We then identified the sources of entrance to the social work unit and screened patients to determine social risk factors . Psychosocial assessment , social needs and social intervention were determined. Following joint consultation with the patient and the medical team, we determined where patients would be transferred for follow up after discharge. The development of this strategy helped the social workers to minimize or avoid dispersion and to tailor the optimal route that each group of patients should follow while in hospital. We were also able to determine the most significative internal and external resources, allowing us to manage and organize the demands of our services. The implementation of this method of generic social work processes and specific procedures has enabled us to define the care continuum and work in a more linear manner, focusing on patients’ real needs.