When should a social worker be ordered for a patient, particularly those with complex psychosocial needs, chronic conditions, mental health issues, or social isolation?

When to Order Social Work Services

Social work services should be ordered immediately when patients present with psychosocial problems (adjustment to illness, family conflicts, social isolation, decision-making difficulties) or practical barriers to care (housing, transportation, financial needs, activities of daily living assistance, caregiver availability). 1

Primary Triggers for Social Work Referral

Psychosocial Problems Requiring Social Work

• Adjustment to illness and quality-of-life concerns 1
• Family conflicts and social isolation 1
• Difficulties in decision-making regarding treatment 1
• Advance directive discussions 1
• Domestic abuse and neglect concerns 1
• Functional changes affecting body image or sexuality 1
• End-of-life and bereavement issues 1

Practical Barriers Requiring Social Work

• Housing instability or homelessness 1, 2
• Food insecurity 1
• Financial assistance needs 1, 2
• Transportation barriers to medical appointments 1, 2
• Help with activities of daily living 1, 2
• Employment or school concerns affecting care 1, 2
• Cultural or language barriers 1, 2
• Lack of caregiver availability 1, 2

High-Risk Populations Requiring Proactive Social Work Referral

Patients with Complex Medical Needs

• Multiple chronic conditions with poor appointment adherence 2
• Severe comorbid illnesses creating barriers to care 2
• Patients with mental health and/or substance use disorders 1
• Older persons with frailty 1

Psychiatric History as a Trigger

• Any history of psychiatric disorder increases risk for distress and requires referral to supportive services 2
• Under-managed psychiatric conditions negatively affect treatment responses for chronic medical illnesses and must be addressed concurrently 2

What Social Workers Provide

For Mild Psychosocial Problems

• Patient and family education 1, 2
• Support group connections 1
• Sex or grief counseling 1
• Linkage to local community resources 1, 2

For Moderate-to-Severe Psychosocial Problems

• Counseling and psychotherapy services 1, 2
• Community resource mobilization 1, 2
• Problem-solving skill teaching 1, 2
• Advocacy and protective services 1, 2
• Care coordination across multiple providers 2

Integration with Medical Care

Direct communication must be initiated between the primary care provider and social worker about the plan for managing both psychiatric and chronic medical conditions. 2

• Social workers coordinate care when patients have multiple specialists and complex medication regimens 2
• The primary care team (physician, nurse, social worker) must work together to screen for distress and practical barriers 1
• At least one team member must maintain familiarity with available mental health, psychosocial, and chaplaincy services in the institution and community 1

Critical Assessment Components

Social Support Evaluation

• Assess adequacy and availability of social support at home 2
• Evaluate caregiver burden 2
• Identify social isolation or lack of close confidants 1, 3

Documentation Requirements

• Confirm documented healthcare proxy is in medical record 2
• Establish emergency contact person 2
• Consider on-person lifeline emergency service if social support is severely limited 2

Common Pitfalls to Avoid

Early social work referral is critical—waiting until problems become severe results in worse outcomes and higher healthcare utilization. 2

• Systematically assess both practical barriers AND psychosocial barriers, as both independently affect appointment adherence and treatment outcomes 2
• Do not assume patients with chronic illness only need medical management; the majority of social needs remain unmet in standard care, with only 33-42% of social needs being addressed 3
• Social isolation and loneliness are common among older adults with chronic conditions and directly impact morbidity and mortality 4, 5

Special Considerations for Specific Populations

Cancer Patients

All new cancer patients should be rapidly screened for distress; those with practical and psychosocial problems should be referred to social workers. 1

High-Risk Veterans and Complex Patients

Cross-cutting issues such as social needs, mental health, functional status, and healthcare access require social work intervention to improve outcomes in high-risk patients with complex care needs. 1