Complex Coordination In Social Work Discharge Planning: Mapping Needs and Patching Resources for Critically Ill Patients and Caregivers Experiencing Financial Hardship

Background & Purpose: Critically ill patients and their caregivers are vulnerable to financial hardship (FH) after a hospitalization. They experience mounting costs, lost incomes, and a cascade of related post-discharge needs that arrive quickly and often unexpectedly. FH is an under-addressed aspect of critical care with negative impacts on long-term outcomes. Social workers routinely receive referrals for FH and are trained to assess, intervene, and advocate for patient and caregiver needs. Therefore, social workers are well-positioned to play a crucial role in interventions aimed at addressing FH. Yet, how social workers address FH in critical care is not well understood. This study examines how social workers working with critically ill patients and their caregivers describe responding to FH and navigating FH supports.

Methods: We conducted 15 semi-structured interviews with social workers who work with critically ill patients and their caregivers in two academic medical systems in the US Pacific Northwest and Mid-Atlantic regions. Eligible social workers were identified by administrators, managers, and clinicians, and recruited via email. Interviews elicited FH needs encountered, available resources, and related structural characteristics of social workers’ practice settings. Interviews were transcribed and analyzed using thematic analysis.

Findings: Participants described a wide range of patient and caregiver FH needs related to a critical care hospitalization, including income loss, insurance gaps, unmet basic and material needs, and barriers to community resources. To address these needs, social workers drew on interprofessional collaboration (e.g., financial counselors, clinicians); community referrals (e.g., food banks, foundation grants); and institutional supports (e.g., meal vouchers, financial assistance), although resources varied by hospital and budget restrictions. Major time constraints, complex cases, rapidly outdated resource lists, and disease-specific resources created barriers to fully and consistently meeting FH needs.

Three overlapping clusters of practice emerged from participants’ accounts of their experiences addressing FH, often occurring broadly under the umbrella of discharge planning:

1. Needs assessment and triage: Anticipating, mapping, and prioritizing financial needs
2. Resource mobilization: Identifying and patching together referrals, benefits, and community supports across fragmented systems
3. Psychosocial and relational labor: Managing expectations, delivering difficult information, and tailoring communication to individual FH needs

Participants described their work as rarely linear, requiring adaptation under time and capacity constraints. Participants described keen awareness that a constellation of social and structural factors influenced the inequitable distribution of FH support. Referral pathways often shaped who was identified for intervention, noting that patients without urgent discharge dates, discernible distress, or strong family advocates were often missed. Staffing patterns, including disruption following the COVID-19 pandemic and variable social worker experience, created structural limitations.

Conclusions & Implications: Findings from this study make visible the range of case- and context-specific activities that are encompassed within social work roles in addressing FH and discharge planning. Participants described navigating FH support without consistent resources or standardized practice guidelines, often absorbing substantial responsibilities for crafting solutions with limited institutional support, despite practicing within interprofessional teams. These findings point to the need for clearer role definitions, equity-focused referral structures, and institutional investment in social work capacity.

Funding: NHLBI 1R01HL162831