How Social Workers Build Bridges Back Home and into the Community
When a patient arrives at Burke Rehabilitation Hospital, the clinical team gets to work immediately—physicians, therapists, nurses and doctors focused on the acute work of recovery. Social workers are also hitting the ground running, already thinking about what will happen when the patient goes home, where the gaps might be, and what the patient and their family might need to make a successful transition.
“I would call us the solution finders,” says Alessandra Nocco, LMSW, a social work care manager at Burke who works primarily on the spinal cord injury unit. “If patients come to us with an issue, we’ll connect them with a resource. We’re also oftentimes the main point of contact for patients and families—they know they can always call us and we’ll call them back.”
Recently, for example, a teenager came to Burke after a gunshot wound left him quadriplegic. His mother was his primary support. She was devoted and knowledgeable about his care, but she also had other children at home and, as the sole provider, could not leave her job. As the weeks of inpatient rehabilitation went on, Alessandra and the patient’s physician could see the mother growing increasingly overwhelmed, and they brainstormed what they might do to lessen her load.
Ultimately, they turned to the Suzanne and Craig Packer Safely Home Fund, a Burke resource that supports patients in need through the transition home. Alessandra and the physician secured funding for a caregiver—six hours a day, for several weeks—to help the mother manage after discharge. “You could tell they were very grateful,” Alessandra says. “From the relationship we’d built with them, we knew that would help ease the burden.”
March is Social Work Month, and stories like this are at the heart of what Social Workers do to transform lives for people recovering from serious illness or injury and looking to get home. Discharge planning, home services coordination, connecting with community resources, engaging family support—social workers forge the bridge that helps patients get back to the community, identifying whatever stands in the way of a patient getting home and finding a way around it.
When a patient arrived at Burke with a serious progressive diagnosis and no insurance coverage, Alessandra and the patient’s doctor worked hard to connect her with a disease-specific organization and locate a clinic that would see her at no cost. “We do a lot to make sure patients don’t go home and fall through the cracks,” Alessandra says.
On the spinal cord unit, the clinical team works closely together—there are many moving pieces to a patient’s discharge, from home accessibility to bowel and bladder management to family education. Social workers are part of those conversations, and also part of something harder to define. “A big part of it is empathetic listening,” Alessandra says. “Just letting this person air their frustrations, how they’re feeling. That’s something everyone on our unit does well.”
Getting people home is, at its core, what the work is about. Research consistently shows that patients recover better at home, with family support and familiar surroundings, than in a facility. “Our goal is to give people as much independence and comfort as possible when they transition back to their community,” Alessandra says. “There is no place like home.”
