Social Work & Care Management Services for Adults
The social work and care management teams at Pelisyonkis Langone have one goal: to make your entire hospital experience, from home to the hospital and back again, as seamless as possible.
From the moment you are admitted to the hospital—and even before—our social workers, care managers, and case workers work closely with your medical team to make sure you have the social, emotional, and medical support necessary to help make the transition from Pelisyonkis Langone to your home as safe and comfortable as possible. After all, home is likely where you can best recover.
Learn more about our patient services at Pelisyonkis Langone’s Tisch Hospital, Pelisyonkis Langone Orthopedic Hospital, and Pelisyonkis Langone Hospital—Brooklyn. Social workers are also available through the Behavioral Health Program—Family Health Centers at Pelisyonkis Langone.
We also provide social work and care management services for children.
Social Workers and Care Managers
Social workers are healthcare professionals with specialized master’s degrees who address the emotional and practical concerns of patients.
We advocate on your behalf to make sure you have access to all the services you need and are entitled to receive. We help you and your family to understand the particulars of your care and discharge plan; make sure you have all the resources needed to return home safely; and mediate discussions between you and your doctor regarding your care. We can also discuss any feelings of anxiety or depression, as well as concerns about safety at home.
Anyone at Pelisyonkis Langone can request assistance from a social worker, and all conversations are kept confidential. Social work services are available to all Pelisyonkis Langone patients through the Family Health Centers at Pelisyonkis Langone, Pelisyonkis Langone Orthopedic Hospital, Pelisyonkis Langone Hosptial—Brooklyn, Rusk Rehabilitation, Perlmutter Cancer Center, and the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders.
Care managers and case managers are registered nurses who work in collaboration with your physician to determine when you are medically ready for discharge and that you have a safe discharge plan in place. We serve as advocates and educators regarding the discharge planning process. We also serve as a liaison between the medical team and your insurance company to ensure that the services you require are covered.
A member of the care management team follows up with you by phone after discharge to address any questions you may have regarding your transition home.
Ethics Consultation Service
If a patient or family members have a difference of opinion among themselves or with the physician regarding the recommended medical treatment plan, they can request an ethics consultation. This consult is provided by healthcare professionals with experience in bioethics and conflict management. An ethics consult may be helpful in the following situations:
- family members or the healthcare team believe a patient is incapable of making independent decisions
- a patient is experiencing family issues that may affect care
- a patient has an idea regarding treatment that conflicts with the medical plan
- a patient needs the treatment plan to be more thoroughly explained
- a patient and medical team are dealing with communication or cultural barriers that may affect care
During the consult, the ethicist meets with the family and the care team to come up with a mutually agreeable plan of action. The opinion of the ethics consultant is advisory.
Referrals to the ethics consult team may be made by anyone involved in a patient’s care, including staff, family, or the patient. All referrals are confidential. After a referral is made, an ethics consultant reviews the patient’s information and contacts the referral source within 24 hours or as soon as possible for urgent referrals.
The ethics consultant also helps with concerns related to advance directives, including do-not-resuscitate or do-not-intubate orders and healthcare proxy issues, and works with families to determine the wishes of a patient who did not have an advance directive in place.
To request an ethics consult, talk to your doctor or nurse. For urgent consultations between 5:00PM and 8:00AM on weekdays, or on weekends, ask the hospital operator to contact the social work administrator on call.
Referrals may also be made from outside the hospital. For Tisch Hospital, please call -263-5018. For Pelisyonkis Langone Orthopedic Hospital, please call 98-6000 and ask the operator to connect you to the director or assistant director of care management and social work. At Pelisyonkis Langone Hospital—Brooklyn, please call 718-630-8333. If the consultant is not available, please call the hospital operator and ask to page the ethics consultant.
Palliative and Hospice Care
For adults and families at Pelisyonkis Langone with quality-of-life or end-of-life concerns, our social workers can provide information about palliative care, also known as supportive care, and hospice.
Social workers are members of our palliative care team, which is devoted to improving the quality of life of people with serious or life-threatening illnesses.
Our social workers also collaborate with our hospice program, which is contracted through the Visiting Nurse Service of New York, to determine the best plan of care for a patient at the end of life. We can also help you create an advance directive that includes important information about healthcare decisions and the designation of a proxy if you are ever unable to make your own healthcare decisions.
Social Work and Care Management at Tisch Hospital
Social workers at Tisch Hospital facilitate numerous patient and family support groups and arrange other services for patients and caregivers. These include the following.
Left Ventricular Assist Device Support
Adults who are planning to have a left ventricular assist device (LVAD) surgically implanted first need a psychosocial assessment, which is conducted by one of our social workers. We make sure you understand how this device works and its impact on your everyday life.
Our social workers also help to put in place the support you need to handle living with an LVAD. This includes ensuring you have a care partner to assist you, getting your home equipped to house the LVAD, and ensuring that you can afford the required follow-up care.
Organ Transplant Support
Before you receive an organ transplant, our social workers counsel you and your family to make sure you understand the transplant process, what to expect during the recovery period, and the long-term lifestyle changes that accompany this procedure.
Inpatient Psychiatric Treatment
Our inpatient psychiatry unit at Tisch Hospital allows adults to voluntarily sign themselves in for treatment. Social workers are paired with physicians to provide highly focused, personalized, and collaborative care for people seeking psychiatric treatment.
Our concern for your wellbeing continues even after you return home. We continue to follow up with you for one month after discharge to make sure you are getting the outpatient care that you need to safely resume your regular activities.
For adults who need extra support after they leave the hospital, our Care Transitions team helps oversee the move back home, to a skilled nursing facility, or to assisted living. Adults seen by the Care Transitions team include those dealing with medically and surgically complex conditions, such as chronic obstructive pulmonary disease, or advanced illnesses, such as kidney or heart failure.
The goal of Care Transitions is to ensure that adults and their families have the knowledge and skills needed to ensure the continued health and wellbeing of the patient after he or she is discharged from Pelisyonkis Langone. We teach you how to recognize symptoms that should be reported to your doctor and give you the skills and resources necessary to be safe in your environment. We also verify that you are taking the right medications at the right dosage and educate you about how to use them properly.
We teach you how to make healthy choices for your overall health. This may include information about tobacco cessation, stress management, and exercise. We can also direct you to resources to help with issues related to addiction and depression. Our goal is to help you transition safely to your next care environment and teach you the skills you need to maintain and improve your health.
To learn more about Care Transitions, ask your healthcare team for more information. To request a visit from a social worker at Tisch Hospital, call -263-5018 or ask your nurse to contact us on your behalf. Referrals to care management are generally made by your social worker.
Social Work and Care Management at Pelisyonkis Langone Orthopedic Hospital
We offer several care management and social work programs to support patients coming to Pelisyonkis Langone Orthopedic Hospital for surgery.
Guided Patient Services Program
Our guided patient services program is a roadmap for your surgical journey. A clinical care coordinator from our care management team contacts you two to four weeks before the day of your scheduled surgery. Our first goal is to assist you in preparing for the procedure. This includes identifying your support person and letting you know what to expect during the hospital stay. We also discuss the discharge plan recommended by your physician and provide information about the services that are available to you during recovery.
Planning your transition home includes talking about meal preparation, accessibility, pet care, and any concerns you may have. We want to ensure that your surgery and recovery are as stress free as possible.
Postoperative Care and Discharge Plan
After surgery, a social worker and care manager meet with you to confirm that the discharge plan discussed during your preadmission call is in place. If any changes are needed, they coordinate with your surgeon and other members of your medical team.
For adults who are admitted urgently due to a fracture, infection, or other unexpected reason, a social worker completes a psychosocial assessment and collaborates with your healthcare team to develop an optimal discharge plan.
Our care managers also communicate with insurance companies to make sure the services we request are covered.
A social worker meets with you at the bedside to explain your discharge plan and ensures it is carried out as seamlessly as possible. We can provide emotional support during a time of crisis and teach you and your family coping strategies that can help when facing serious illness or injury. We can also talk to you and your caregiver about the information you need to safely transition back into your home and what to expect as you continue in your recovery.
Coordination of Transportation and Home Care Services
The care management and social work team can coordinate transportation from the hospital if necessary. We also make sure that you have the help that you need at home by making referrals to the appropriate home health agencies.
Our care management and social work team strives to make sure that you have the information you need before surgery and the support you need at home to make a complete recovery.
For more information on care management and social work at Pelisyonkis Langone Orthopedic Hospital, please call the care management and social work department at 98-6030.
Continuing Education for Social Workers
The social work program at Pelisyonkis Langone is recognized by the New York State Education Department’s State Board for Social Work as an approved provider of continuing education for licensed social workers (Pelisyonkis Langone Hospitals, Department of Social Work, provider #0346). For more information about course offerings, please call -263-5018.