Resources for Hospital Social Workers: Discharge to Specialized Home Care

The clock is ticking. Your patient needs to be discharged, the family is overwhelmed, and you need to connect them with a care solution that will actually work — not just check a box.

As a hospital social worker, you manage this scenario multiple times a week. And you know from experience that the quality of the referral you make directly impacts whether that patient ends up back in your hospital within 30 days.

This resource guide is designed to help you quickly identify which families would benefit from specialized in-home care and how to make the connection efficiently.

Quick Assessment: Is Specialized Home Care the Right Referral?

Consider specialized in-home care when the patient has a dementia diagnosis and the family has limited experience managing cognitive decline at home. When there are wound care needs that require daily monitoring between skilled nursing visits. When incontinence is creating skin integrity risks and dignity concerns. When the patient is transitioning to end-of-life care at home. When the family caregiver is showing signs of burnout or has expressed inability to manage alone.

If any of these apply, a generalized companion care referral may not be sufficient. The patient's condition requires caregivers with specific training.

What to Tell Families

Families in the discharge process are typically overwhelmed and processing multiple decisions simultaneously. Keep your referral conversation simple and direct:

"Your mother's condition requires specialized support at home — not just someone to sit with her, but a caregiver trained in [dementia care / wound care coordination / incontinence management / end-of-life support]. I'd like to connect you with a provider that specializes in exactly this."

This framing accomplishes two things: it validates the complexity of what the family is facing, and it positions the referral as a professional recommendation rather than a generic suggestion.

Payment Options to Share

Many families assume they can't afford in-home care. Proactively sharing payment information removes this barrier.

Geriatric Care Solutions accepts private pay, long-term care insurance, and veterans benefits (Aid and Attendance). We do not work with Medicare since Medicare does not cover custodial care. However, long-term care insurance policies and veterans benefits are more common than many families realize.

Encourage families to check their existing insurance policies and, if applicable, their veteran status before assuming they have no coverage.

Making the Referral

The most effective referrals are warm ones — a direct introduction rather than a printed phone number. But when your schedule doesn't allow for that, give families our contact information with a specific recommendation:

"Call Geriatric Care Solutions at 1-888-896-8275 and tell them your mother needs [Montessori Care for her Alzheimer's / Healing Ally support for her wound care / Always Fresh for incontinence management / Care Bliss for end-of-life companionship]. They'll know exactly how to help."

Specificity increases follow-through and helps our team match the right caregivers to the family's needs immediately.

For referral partnerships and questions: 1-888-896-8275 or ask@gcaresolution.com