Building the Bridge from Hospital to Home

Building the Bridge from Hospital to Home

Sabrina Gaon and Revital Shuster

Sabrina Gaon MSW, RSW, and Revital Shuster, MSW, RSW, spoke about the Social Work Care Navigator program during Social Work Week.

An innovative partnership between social workers at Circle of Care and Mount Sinai is ensuring that hospital patients have a smooth transition home, and avoid future visits to visits to crowded emergency departments or a hospital readmission.

The Social Work Care Navigator program was highlighted at a Mount Sinai Lunch & Learn session in recognition of Social Work Week (Mar. 5-11). At the helm of this collaborative initiative is Circle of Care Social Worker Revital Shuster, whose expertise in home and community care helps connect patients and their families to the right resources and supports to keep them healthy at home.

In this model, Care Navigators are matched with patients (and family members) who are nearing discharge, and have complex medical needs that require significant post-discharge support. “If the patients are set up to be well supported at home, the anxiety levels of both the patients and family members are significantly lowered, and we’re less likely to see them back in hospital,” Shuster said.

“The Care Navigator is a helpful bridge from hospital to home,” said Sabrina Gaon, Manager of Interprofessional Allied Health for Social Work and Clinical Nutrition at Mount Sinai. By working side by side, the hospital social workers and the Care Navigator can depend on each other for support in complex cases, and to fill in any missing pieces that will lead to a more seamless transition, she said. “Revital’s role has brought a lot more confidence to the social work team at Mount Sinai Hospital.”

When it comes to anticipating post-discharge needs, there is definitely no one-size-fits-all solution, said Shuster, who will follow patients for anywhere from 30-90 days to ensure a successful transition. In one case, a patient’s family members were insistent about admission to long-term care following discharge but the patient was adamantly against the idea. As a compromise, Shuster was able to negotiate a six-week stay at nearby facility until she was able to locate permanent housing within a supportive housing complex. In another case, an elderly patient whose landlord would not permit visits from a home care provider had been visiting the ED daily to have his leg wounds cared for. Shuster intervened by educating the landlord on tenant rights, and also put community supports in place including visits from an RN and meals on wheels delivery.

The program is a pilot project funded by the Max and Larry Enkin Family Foundation, and one of Sinai Health Systems first integration initiatives. Its success has led to the adoption of Circle of Care Navigators at other sites, including UHN, the Mount Sinai Hospital Family Health Team (Sherman Health and Wellness Centre), and within a new ALC transition program based at the Wellesley site of long-term care provider Rekai Centre.

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