Medical social services at home
Medical social workers who help families navigate the system: community resources, caregiver support, advance directives, and the practical problems that get in the way of recovery.
What's included
- Community resource referrals
- Caregiver counseling and support
- Long-term care planning
- Advance directive and POLST guidance
- Financial and insurance navigation
- Transportation and meal-program coordination
- Safety and elder-protection concerns
- Support during a difficult diagnosis
How it works
- Physician order. Your doctor, or the hospital at discharge, sends us the order.
- Eligibility check. We verify Medicare or insurance before the first visit — no surprises.
- Start of care. A registered nurse visits within 48 hours and writes the plan of care.
- Visits. medical social services visits follow the plan; progress is reported to the physician.
Questions about medical social services
What does a medical social worker actually do on a home visit?
They assess what is standing between the patient and a stable recovery — an exhausted caregiver, an unpaid utility bill, no ride to dialysis — and connect the family to the right program or service.
Is this counseling?
It includes short-term supportive counseling for the patient and family, and referrals to longer-term mental-health support when needed.
Can the social worker help us plan for what comes next?
Yes. They can explain options such as in-home caregivers, assisted living, hospice, and Medi-Cal programs, and help the family make a plan.
Is a social work visit covered?
Medical social services are covered by Medicare as part of the home health benefit when they are part of the plan of care.