Social Work Referral (Inpatient) 🤝
Guide for inpatient medical social work referral. Key information for discharge planning, home support, Fair Deal, safeguarding, housing, and psychosocial support, with HSE scheme links for NCHDs.
📋 Key Info to Have Ready
- Patient identifiers: name, DOB, MRN, ward and bed location
- Reason for referral, being specific: discharge supports, Fair Deal, home support, housing/homelessness, carer strain, counselling, safeguarding, or finances/benefits
- Baseline living situation: lives alone or with others, house vs apartment, stairs, heating, access to food and transport
- Current supports: family/friends, existing HSE home support hours, PHN, day centre, private carers
- Functional status and medical plan: mobility, cognition, prognosis, and anticipated discharge destination/timeframe
- Next of kin / next of kin gaps: who is involved, who has decision-support arrangements, and whether collateral is available
- Practical barriers: no fixed address, rent/mortgage risk, no medical card, no transport home, caring responsibilities for children or dependants
- Safeguarding or welfare concerns (and whether already escalated to senior, Gardaí, or Tusla)
- Urgency: safe for discharge today/tomorrow vs complex placement needing days to weeks
🔎 Common Reasons to Refer
- Complex discharge: needs home support, increased package, equipment plus psychosocial planning, or uncertain destination
- Application support for HSE Home Support Service (formerly home care package) while an inpatient
- Long-term nursing home care pathway and Fair Deal (Nursing Homes Support Scheme) applications
- Housing or homelessness: no safe discharge address, sofa-surfing, eviction risk, or need for temporary accommodation liaison
- Carer strain, family conflict about care options, or need for family meetings about prognosis and discharge
- Emotional or psychosocial support after new diagnosis, bereavement, trauma, or major change in independence
- Financial or benefits barriers affecting discharge: medical card, social welfare, inability to collect meds or food
- Adult safeguarding concerns: neglect, financial abuse, coercive control, self-neglect (also follow local safeguarding pathway)
- Child welfare concerns linked to the admission (also report via Tusla / Gardaí as required; MSW supports but does not replace mandated reporting)
- Addiction, domestic violence, or inclusion-health needs where hospital MSW or linked services can connect supports
📞 Example Referral
- Hi, this is [Your Name], the intern from [Team Name]. I'd like to refer a [Age]-year-old patient on [Ward] to medical social work.
- They were admitted with [reason] and are now medically [stable / improving / for palliative pathway]. We're referring for [e.g. home support application / Fair Deal / housing / family support / safeguarding advice].
- At baseline they [lived alone / with family] in [housing type], with [supports, e.g. no formal home support / X hours home support]. Currently they need [e.g. help with ADLs / cannot return upstairs / no safe address].
- Cognition is [intact / fluctuating / impaired]. Next of kin is [name/relationship] and [is / is not] available. Discharge aim is [home with supports / rehab / nursing home / uncertain].
- Specific concerns: [e.g. carer burnout, unpaid rent, domestic violence disclosure, self-neglect, dependent children at home].
- Many hospitals use an electronic or paper referral rather than a phone call. Include the same details there, and phone MSW directly if discharge is imminent or if there is an urgent safeguarding concern.
📝 Tips
- Refer early. Home support and Fair Deal take time; last-minute referrals delay discharge.
- Be specific about the ask (e.g. "needs home support application and family meeting") rather than "social work review".
- MSW coordinates psychosocial and practical supports. OT/physio still need separate referrals for function, equipment, and mobility.
- For Home Support while in hospital, ask the discharge coordinator or MSW for the application form early (HSE: apply as soon as possible during the stay).
- Fair Deal is for long-term nursing home care, not short respite or convalescence. Incomplete forms and missing financial documents are the usual delays.
- Safeguarding and child protection: escalate same day via local policy (senior, Designated Officer, Tusla portal, Gardaí out of hours). Do not wait for a routine MSW slot if the person is at immediate risk.
- Document capacity and any decision-support arrangements when discussing placement or finances; involve senior/team if capacity is unclear.
- Raise complex discharges at MDT so MSW, OT, physio, SALT, dietetics, and the discharge coordinator share one plan.
- Weekend/OOH MSW cover is often limited. Flag urgent cases before the weekend and leave a clear written plan.
Educational reference only. Medical disclaimer