msw service protocol stroke care

8/14/2019 Msw Service Protocol Stroke Care

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Service Protocol for Stroke Care (MSW)

Introduction:

Depending on individual circumstances and need, medical social services are available to all stroke patient

services are provided to patients and their families to meet their medically related social and emotional neecondition, treatment, recovery, and safe transition from one care environment to another. The primary goal o

the effectiveness of rehabilitation in helping the person with disabilities from a stroke to achieve the best pos

of life. Overall speaking, this Service Protocol can be applied both for acute and rehabilitation institute. Nev

are only applicable to either one setting.

Goals of MSS in Stroke Care:

1. Enhance stroke patients and family's quality of life, psychosocial and emotional well-beings through p

services.

2. Promote the patient-and-family centred nature of rehabilitation and the importance of capitalizing strengths and potentials during the rehabilitation process.

3. Facilitate community integration of the stroke survivor with disabilities.

Major Problems of Stroke Patient and Family

1. Problems related to patient care and activities of daily living.

2. Patient and family adverse reactions or dysfunctional adjustment to illness and change in functional statu

3. Family relationship problems due to the change of roles and functions in the family

4. Emotional problems, including depression, anxiety and career stress

5. Discharge problems

6. Financial and housing problems

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Key Stages/Tasks Principles Interventions

Psychosocial

Assessment

MSWs should systematically assess the patients psychosocial conditions.

Review or evaluate at key stages throughout acute care and rehabilitation.

Conduct PsychosocialAssessment

Idenitify problem area Make intervention plan

Crisis Intervention

(if applicable)

There are times of acute difficulty after stroke, eg. Suicidal ideation, care

problems of dependent family members. MSWs are expected to contact

patients and their families and render necessary services within 1 working day

Provide Crisis Intervention,contact family member/

caregiver (if available)

Problem Solving Anxiety and emotional disturbances are common after stroke. Counselling

service on patient and family's acceptance of illness and emotion is required.

Social problems, like financial, accommodation, home care and discharge are

common after stroke. Hence early mobilization of community resources to

assist patient and family is necessary.

Provide counselling on:1. Social and emotional

functioning of patient

and family caregivers

2. Stress management/handling of emotions

Mobilize appropriatecommunity resources as early

as possible

Provide psychosocialeducation & intervention

information


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Goal Setting and

Formulation of

Rehabilitation Plan

Facilitate the communication and participation among patient, family and

rehabilitation team in goal setting and formulation of rehabilitation plan.

Reflect and discuss thepatient's psychosocial needs

and family circumstance in the

multi-disciplinary care plan.

Motivate patient and familyparticipation in the

rehabilitation process.

Finalize the discharge plan:1. Review psychosocial

conditions for formulating

the goal of discharge plan.

2. Assess caregiverscapabilities and other

practical arrangement to

care the stroke survivor.

Discharge Planning Discharge planning should begin on the day of admission

The ability of a stroke survivor to return home depends on the persons needs

and the availability of caregivers support. If patients need exceed caregivers

capabilities, community support services and/or alternate long-term placement

should be considered.

Liaise and mobilize communityresources.

Share and discuss the dischargeplan with the multi-disciplinary

team.


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Transition to

community

MSWs should be sensitive to the impact of care arrangement to patient and

caregivers. They should work with the patient and caregivers, to promote their

problem solving ability and facilitate reintegration of the patient into

community.

Complete thepre-dischargechecklistand take necessary

action as indicated.

# remarks

Complete transfer summaryand send to other MSW/ Send

referral to welfare agencies, if

applicable.

Post-discharge

Case review and

follow up

(if applicable)

Based on existing screening mechanisms for high-risk case eg. CNS, home-

help team, informal carer, Allied Health Community Programme etc. to

identify needy patient and family for case review.

Review on psychosocial, emotional and family functioning. Follow up the

identified problems and render appropriate services.

# remarks

Conduct case review Review thepre-discharge

checklist.

Re-assess caregiverscapabilities and other practical

arrangement to care the stroke

survivor.

Liaise and mobilize communityresources.

This protocol is based on the Clinical Practice Guideline Post-Stroke Rehabilitation: Assessment, Referral, and Patient Managementpu

Human Services, Public Health Service, Agency for Health Care Policy and Research, 1995.

Remarks:

# Case can be closed when necessary social work intervention is completed.


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Case Evaluation Form on Service Protocol for Stroke Care in Acute Unit (MSW)

MSS No.: Age/Sex: Aged home resident: yes/no Specialty: Med/Geri/Rehab/Stroke Care Unit/ Other

Key Stage/ Tasks Intervention Done Not Done

State reasons

Time

1) Conduct psychosocial assessment

2) Identify problem area

I Psychosocial

Assessment

3) Design intervention plan

2 working days u

case referral

II Crisis Intervention(if applicable)

Provide Crisis Intervention Response within

1) Provide Counselling (pls refer to protocol p.2)

2) Mobilize appropriate community resources

III Problem Solving

3) Provide psychosocial education & intervention information

Response within

1) Reflect & discuss the patients psychosocial needs & family

circumstances in the multi-disciplinary care plan

IV Goal Setting &

Formulation of

Rehabilitation

Plan

2) Motivate patient & family participation in the rehabilitation

process

On-going

1) Review psychosocial condition & finalize the discharge plan 2 days before di

2) Liaise & mobilize community resources

V Discharge

Planning

3) Share & discuss the discharge plan with the multi-disciplinary team

Upon discharge

1) Complete the pre-discharge checklist and take necessary action

as indicated.

Upon dischargeVI Transition to

community

2) Complete transfer summary & send to other MSW/ Send referral

to welfare agencies, if applicable

5 working days a

Reason for post-discharge review eg. Financial problem, caring problem etc:

1) Conduct case review

2) Review the pre-discharge checklist

3) Re-assess caregivers capabilities & other practical

arrangement to care the stroke survivor

VII Post-discharge

Case review &

follow up

(if applicable)


2 working days a

notification

Name of Hospital: Completed by :


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Case Evaluation Form on Service Protocol for Stroke Care in Rehabilitation Unit

MSS No. : Age/Sex: Aged home resident: yes/no Specialty: Med/Geri/Rehab/Stroke Care Unit/ Ot

Key Stage/ Tasks Intervention Done Not Done

(State reasons)

Time

1) Conduct psychosocial assessment

2) Identify problem area

I Psychosocial

Assessment

3) Design intervention plan

1 week after admis

3 working days up

referral form

II Crisis Intervention

(if applicable)

Provide Crisis Intervention Response within

1) Provide Counselling (pls refer to protocol p.2)

2) Mobilize appropriate community resources

III Problem Solving

3) Provide psychosocial education & intervention information

Response within

1) Reflect & discuss the patients psychosocial needs & family

circumstances in the multi-disciplinary care plan

IV Goal Setting &

Formulation of

Rehabilitation Plan 2) Motivate patient & family participation in the rehabilitation process

On-going

1) Review psychosocial condition & finalize the discharge plan 3 days before di


V Discharge

Planning

3) Share & discuss the discharge plan with the multi-disciplinary team

Upon discharge

1) Complete the pre-discharge checklist and take necessary action

as indicated.

1 working day beVI Transition to

community

2) Complete transfer summary & send to other MSW/ Send referral

to welfare agencies, if applicable

5 working days a

Reason for post-discharge review eg. Financial problem, caring problem etc:

1) Conduct case review

2) Review the pre-discharge checklist

3) Re-assess caregivers capabilities & other practical

arrangement to care the stroke survivor

VII Post-discharge

Case review &

follow up

(if applicable)


2 working days a

notification

Name of Hospital: Completed by :


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MSW Transfer Summary

From : To:

Ref: Ref:

Fax/ Tel: Fax:

Date: Date:

I) Particulars

Name of patient: ( ) Sex: M/F* Age/D.O.B:

HKIC/BC No.: Marital Status: S / M / W / D / Cohabited / Separated*

Address: Tel. No.:

Accessible by lift Yes No Climb floor. Type of accommodation Dialect

Occupation: Income: Diagnosis: Date of Discharge/Transfer:

II) Particulars of Family Members: (Please provide telephone no. and address as far as possible.)

Name Relationship Sex/Age Occupation/Income Telephone No. Remarks

III) Problem Nature:

IV) Service rendered:

1. Social Investigation/ Enquiry

2. Counseling on: Marital Relationship Child Care Others:

3. Financial assistance: A total sum of $ from Trust Fund for the purpose of

was granted on

4. Full/ partial waiver of medical charge (amount waived: $ per day / attendance) from/on to .

(for details pls refer to Application for Waiving of Medical Charges)

5. Processing of: MEF MAF(CSSA/SSA) SSFU ref:

6. Referrals Made: Residential Service for Elderly Home help / Home care Day Care Centre for Elderly

Enhanced Home &Community Care Services Halfway House

Sheltered Workshop Supported Employment Selective Placement

Long Stay Care Home

Day Activities Centre

MH Hostel

Others:

V) Suggested Follow Up Area(s):

VI) Remarks:

Signature: Counter-signed by:

Name of Referring MSW: Name/Post :

Telephone No.: Date: Date:

* delete if not applicable Ver-402

Appendix 3


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Reply Note

From : To:

Ref: Date:

We will follow up this case and render appropriate assistance to the above-name. Forenquiries, please contact the responsible Medical Social Worker Mr/Mrs/Ms

at .

Other remarks:

Signature:

Name of MSW:

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(Please Affix Patients Label Here)

Appendix 3

msw service protocol stroke care

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