The Hospital-to-Home Social Work Handover

Link discharge planning to the ‘first week at home' realities.

A discharge may be clinically appropriate while food, home access, worker support and follow-up are still unknown.

Community services and hospital systems have different time requirements. Without a named bridge, referrals can sit unactioned, leaving the person and family to carry the gap.

Why this matters for social workers

Social workers will provide context to arrangements that can be task-focused. The challenge is to put that understanding into action without compromising privacy, dignity and self-determination. Useful coordination is linking the person's story to the current preferences, barriers and support needs, and then clarifying the next responsibility without making one professional the owner of all the issues.

What better coordination looks like

Social workers can create a short home-readiness snapshot that separates requests from confirmed arrangements and highlights the unresolved dependencies.

Plan the first day

Verify transportation, entry, equipment, medication info, meals, personal support and who will check in.

Confirm the first week

Make a list of appointments, rostered support, involvement of family, warning signs and who to contact for practical issues.

Share a usable handover

Send the minimum necessary information to accepted services with consent and confirm receipt.

Make the change last

A useful change is specific enough to practise; it's small enough to review. Decide who will act first, where the decision will be noted and when the individual will be asked if it helped. In the event that this approach relies on multiple services, the multiple services' responsibilities must be verified individually, not at the meeting. Keep what is working, change what is not, and eliminate temporary solutions that are no longer serving the desired result.

Questions for the next review

What would “plan the first day” look like from the person's point of view?

What is the confirmed element in the arrangement and what is the remaining element that is an assumption or a request?

What will happen that will give the person and team an indication that this is working?

Keep the boundary clear

The final decision on discharge is up to the treatment team. Community capacity should be represented accurately and clinical concerns should be addressed through the health pathways.

A practical example

The social worker's 48-hour check found that the planned morning service had been referred but had not accepted the referral. An alternative was arranged before discharge, not the next day.