The Aunt Bertha Blog

Five Things to Consider in Your Social Service Coordination Efforts

People in need, as well as those helping them, have traditionally encountered many challenges around finding and connecting to the programs and resources that can help them. For individuals, especially those without easy internet access, it’s difficult to uncover the state and government-funded programs for which they qualify and even more so to discover the myriad of private and charitable resources available.

Case workers, social workers, families, and others in a helping role are presented with another set of challenges including time constraints, unstructured data, incorrect or outdated information, and lack of insight into programs and services available outside of their local areas.

For care teams, a lack of formal processes around identifying patient social needs and follow up also make it nearly impossible to ‘close the loop’ on whether the patient was able to connect and receive help after the referral was made.

To make matters more difficult, not everyone is comfortable offering information about their personal needs and those needs often go undiscovered, undocumented, and excluded from the care plan. Expeditious and personalized social coordination is key to improving many of the metrics health care organizations are tracking for success and is no longer a component of patient care that can be ignored without consequence. 

As people begin working to organize or increase social service coordination within their care settings, here are five areas to consider:

  1. COMMUNICATION. Make sure questions around social needs are part of the process at various stages of the patient journey. People have different comfort levels with different staff members. Don’t leave it to discharge planners alone to uncover outside factors influencing patient health and wellness. In addition, work to improve communication and collaboration among care teams at all points along the care continuum. According to expert Cheri Lattimer, Executive Director for the Case Management Society of America (CMSA) and National Transitions of Care Coalition (NTOCC), integrated care teams that effectively communicate during transitions and throughout the other stages in the patient journey see higher staff and patient engagement, as well as, an overall improvement in health outcomes. 
  2. ALWAYS INCLUDE CASE MANAGERS/SOCIAL WORKERS. Keep case management and social service teams in the loop at all times. Their function is an integral part of a patient-centered care plan.
  3. STANDARDIZE. Set up a uniform way to manage social coordination within the organization and work to get everyone ‘on the same page’. It will enhance efficiencies and make it easier to track progress. Providing standardized tools and processes will also help care teams eliminate information silos and function more cohesively when addressing patient needs that fall outside of the medical spectrum.
  4. EMPOWER. Empower everyone (including the patient and those helping him) to get involved in creating a good outcome. One way is by providing an easy way for everyone to find and connect with the programs and services that can help them stay well. Since patient needs outnumber staff resources, facilitating patient involvement is a good way to distribute the case load. Most people want to help themselves and are willing to take the proper steps if pointed in the right direction. 
  5. Analyze the data and monitor trends. Uncovering service gaps can provide insight and drive smarter decisions within the organization. Efficient and timely social coordination improves health outcomes, as well, as patient satisfaction. 
Social factors impacting patient health is no longer a topic of discussion solely reserved for discharge planners coordinating transitions. It’s in the best interest of everyone involved in the patient’s journey to be informed and empowered to help when necessary.
Topics: Social Services access to social services care coordination