Discharge Planning

Social Work Department is available to assist patients of all ages and their families with their psychosocial and discharge planning needs.  The Department is staffed with Licensed Social Workers who work in close collaboration with Physicians and other members of the multidisciplinary team to ensure safe transition from the Hospital.

Discharge Planning is a process that identifies the needs of the patient for a smooth and safe transition from hospital to home or another level of care in another facility.  Discharge Planning can start as early as on the day of admission.  The Social Worker will conduct the assessment for High Risk patients to determine the need for post hospital care and engage the patient and/or families for the development of the plan and coordinate with outside resources for arranging the services.  The patient and family can also request the Social Worker for discharge planning through the phone call to Social Work Department or speaking with Nurse or Physician.  

Discharge Planning, also known as “Transition Planning” can be very complex & challenging as it requires communication and collaboration between patient, family and/or caregiver, hospital staff, insurance companies and community service organizations.  Therefore early involvement of the family is highly encouraged.  The following tools can be very useful to understand the process & prepare the family for their expected role in the process:

  • Medicare.gov – “Your Discharge Planning Check List”
  • www.patientsafefty.org – “Your Path to Being As Empowered Patient”
  • Agency for Healthcare Research and Quality (AHRQ) – “Taking Care of Myself”:  A Guide for When I Leave Hospital
  •  A list of Nursing Homes and Certified Home Health Agencies is available from the Social Worker for patients identified having the need for homecare or placement.  Also CMS website on Nursing Home Compare and Home Health Compare can be reviewed for “Your Guide to Choosing a Nursing Home”.

Counseling, Education, Advocacy & Referrals to Community Agencies are provided based on psychosocial and medical needs as well as cultural and religious preferences of the patient.

The common situations needing Social Work Services are:
  •  Placement in another level of care facility (Nursing Home or Rehabilitation)
  •  Homecare
  •  Suspected abuse/neglect (child or elderly)
  •  Undocumented or Undomiciled patients
  •  Victims of crime, disaster, rape, DV (Please refer to VITP on website for available services)
  •  Teenage pregnancy, fetal demise, adoption, still birth
  •  Mental Health issues
  •  Substance abuse
  •  Urgent concrete services such as shelter, food, clothing, medical equipment etc.
  •  Diagnosis-based psychosocial and Discharge Planning Services for cancer, diabetes, CHF, tuberculosis, terminally ill, HIV/AIDS, CVA, renal failure,  respiratory failure
  •  Death & Bereavement
  •  Crisis Intervention
  •  Caregiver’s support

Hours of Operation
  • Services are available 9am to 5pm, Monday through Friday
  • Weekends & holidays: Social Worker can be contacted through Hospital operator at 718-963-7272
  • During non-business hours, direct messages can be left on voicemail which will be followed up the next business day.  The Director remains on call for emergency situations.


Discharge Coordinator
718-302-8538
(for patient related information & request to speak with Social Worker)

Administrative Assistant
718-963-7261
(for office matters)

Supervisor
718-963-7696

AVP for Care Coordination
718-963-7221
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