An elderly client is being discharged from the hospital. She has memory loss and trouble performing activities of daily living, and therefore needs significant support. She would like to return home. In this situation, what should the social worker do FIRST?

• A. Identify natural and other community supports that can assist her at home
• B. Help to develop a long-term plan to meet her increasing care needs
• C. Evaluate why she is failing to recognize the need for out-of-home care
• D. Recommend that she visit an assisted living program to see if she might like it

Answer: (A)

When an elderly client wants to go home after a hospital stay, the first step is to identify natural and community supports that can help her stay safely at home. This means mapping out what resources are available to support daily living and health needs—such as home health aides, meal delivery, transportation, caregiver support, adult day programs, safety adaptations in the home, and access to community services. By identifying these supports right away, you can determine what level of at-home care is feasible, address immediate safety concerns, and lay the groundwork for a workable discharge plan.

Long-term planning and additional care options come after you’ve mapped the practical supports at home. It would be premature to focus on out-of-home care or to push for an assisted-living option without first knowing what community and home-based resources can be mobilized to enable the client to remain at home.