Hospitals are active, noisy places with staff rushing between units, pagers beeping, alarms sounding and visitors coming and going. Social workers are rarely found in quiet offices; instead they spend most of their time with patients, on rounds or in team meetings. There is often a great sense of urgency. The relationship between social workers, nurses and doctors is crucial and effective communication plays an important part in ensuring discharges or transfers are safe and timely.
Coventry is a diverse city and we support people in the social work team at University Hospital which reflect its community. An ordinary day in the social work team can present us with extraordinary situations, circumstances and solutions. We work with adults age 18 to 110. With issues ranging from self-neglect, declining health, mental health issues, drug and alcohol dependency to give a few examples.
Our team is made up of Social Workers and Community Case Workers supported by a management and administration team. We work in partnership with the Integrated Discharge Team, this team is made up of nurses and therapists. We are also co-located with Age UK. Age UK support hospital discharges and follow people through in the community. We work closely with health professionals based both in and outside of the hospital to achieve the best outcome for those we work with.
One of our main roles is supporting timely, safe hospital discharge to people’s own homes where possible. We take a pride in ensuring we work with people to find out their wishes and outcomes to ensure they are able to return home safely. We work in the emergency department and the short stay wards to prevent unnecessary hospital admissions, support people within the community to access support, via community resources, health and social care support. In addition to this we work with ‘frailty service’. The frailty service is GP led service, based at the hospital the function of which to avoid unnecessary hospital admission for people who are frail and have declining health and to manage complex discharge and put in place a range of support, to include post discharge monitoring at seven and thirty days.
We receive referrals from colleagues within the hospital and this can include referrals from West Midlands Ambulance Service. We are asked to complete our assessment once the person is medically stable and arrange discharge within 72 hours of the referral. The most important person to consult in this process is the individual themselves or their advocate. By working with the person we are able to determine their needs and preferred outcomes. We are then able to formulate care and support plans. Safeguarding or care concern referrals are a large part of our work and we receive these on a daily basis.