Mrs. Smith is a 78-year-old, widowed woman who is admitted to a skilled nursing home for rehabilitation services following a stroke. She is a thin, frail woman with dyed red hair and ruby lipstick. She is alert; is oriented to person, place, and time; and is able to participate in her care and decision-making. The stroke, which occurred on the right side of her brain, has resulted in left-side hemiparalysis. She lives alone in a second-floor apartment with no elevator. She has no family or close friends, although she does know a few of the neighbors in her building.

Mrs. Smith`s stay in the skilled nursing home is covered by Part B of her Medicare as long as she is receiving skilled care. This includes her physical therapy. Medicare will cover this care at 100% for the first twenty days and then at 80% for the next eighty days as long as she needs skilled services and is making progress. Because she has no other insurance to cover the balance of the 80 days that Medicare will not cover, the social worker initiates a Medicaid application. Medicaid will also cover her stay if she needs to remain in the nursing home for more than 100 days.

Many large nursing homes are required by state laws to provide social work services to their residents. The social worker for this facility, John, has a BSW degree. He completes a psychosocial assessment on Mrs. Smith and sees her regularly to provide support and encouragement during her stay. When it is time for discharge, Mrs. Smith is able to perform some of her activities of daily living with adaptive equipment from the occupational therapist, but she is unable to walk and must use a wheelchair. She also has difficulty transferring from a bed or chair into the wheelchair. The doctor recommends twenty-four-hour supervision, but Mrs. Smith has no funds for this service and no one is available to serve. She insists on going home alone, despite John`s efforts to help her accept the risks involved. The doctor wants John to petition for a guardian, but John and the psychiatrist agree that the patient is competent to make her own decisions. John orders a visiting nurse, Meals on Wheels, and a hospital bed, commode, and chair. John also completes a chore grant application with the Department of Human Services to pay for some housekeeping and personal-care assistance. Because Mrs. Smith is unable to get into her home on her own, John orders a wheelchair van to transport her. Because he is so concerned about Mrs. Smith, John takes the rare step of accompanying the patient to her home at discharge. When he is confident that she is settled and seems safe, John leaves. A neighbor will bring her dinner in the evening , and the visiting nurse will check on her in the morning. John feels that he has done his best in this case.

The next morning, John comes into work to find a tearful message from Mrs. Smith. During the night she attempted to use her commode and fell while transferring from the bed. She is back in the hospital, and it appears that she has broken her hip. John contacts the social work department at the hospital and asks them to see her and checks on her himself on his way home from work. Mrs. Smith now accepts that she cannot manage alone at home and will need to move into a basic nursing home or a home for the aged when she has completed treatment for her broken hip. John tells her that he recognizes how difficult this is for her to accept and says that he admires her strength and courage. He asks Mrs. Smith for permission to talk to the social worker so that she may know the efforts and arrangements that had been made. The hospital and social worker collaborate, and Mrs. Smith is placed in a nursing home with skilled care for therapy while her hip heals as well as a home for the aged unit, which will accept her Medicaid and Social Security when the therapy is done.

John reflects back on the case, wondering if he had done everything he could. On the one hand, he felt like he had put a great deal of work into making arrangements that lasted less than twenty-four hours. However, he also felt that trying to live at home even for one night helped Mrs. Smith more realistically accept her situation.

1. Did John did everything that he could have done?

2. As a social worker, What might you have done?

3. Think about all the services John put in place. Are there more services to have considered? Is this is a complex or routine case?

4. Does the social system provides adequate care and support for people like Mrs. Smith? What policy/program innovations are needed?

5. What are the emotional issues that Mrs. Smith was dealing with? How would you help her to deal with these issues?