T/JSSG 002-2020 Discharge Preparation MSW Service Guideline
T/JSSG 002-2020 Discharge Preparation MSW Service Guideline
Basic Information
Scope
Scope: This standard specifies the general principles, basic requirements, service processes and requirements, service models, service quality management, risk management and handling, etc. of discharge preparation medical social work services. This standard applies to medical institutions, rehabilitation nursing institutions, and medical social workers providing community and home-based services that carry out discharge preparation services. Main technical contents: Medical social workers should provide, but are not limited to, the following services: — Professional assessment: Cooperate with doctors and nurses to conduct professional assessments of inpatients to understand their care needs and medical experiences, etc. — Team cooperation: Establish a cooperation team within the hospital and formulate discharge preparation plans, etc. — Referral services: Assist in formulating referral plans and refer patients in need to relevant rehabilitation institutions, etc. — Follow-up visits: Regularly track the patients' conditions, rehabilitation progress, satisfaction with referral services, evaluate the service status of referral institutions, patients' feelings, and service improvement goals. — Information consultation: Provide consultation services on medical assistance policies, relevant laws and regulations, and follow-up service needs, etc. — Resource linkage: Build a social resource service network and referral resource network, and carry out resource evaluation and linkage services. — Rehabilitation guidance: Provide home-based rehabilitation guidance services for patients undergoing home-based rehabilitation, and link to relevant resources when necessary. — Home care: Provide "Internet + nursing" home care services, and carry out service promotion, introduction, and usage guidance, etc.