Please answer the following questions when creating your journal entry.  Feel free to use references, share links, media, pics, and other items that you feel would help your teammates.

• How does your agency help the client define their presenting problem (what assessment tools are used)?
• How are clients included in goal setting?
• Do you have difficulty in promoting client self-determination?  Why or why not?  What if the client is making a “bad decision”?
• How does your agency measure a client’s success in reaching their goals?  How do you know if a client has reached a goal?
• How would you use your client’s baseline to assess progress/change?

Name: Elizabeth Prophete

Agency: Orlando Health REACH

• At Orlando Health with the REACH team, the Social Workers are provider assessments that are to be completed depending on the clients that we are serving. There are short bio assessments for individuals who are primarily stationed in the Winnie Palmer and Arnold Palmer hospital. We also have assessments that are for the elderly and for the medically underserved population. There are a series of questions that we ask the clients and from those questions we are better to understand where the clients are and what they need assistance with. The assessment allows the clients to verbalize what their current problems are. Although they are told in advance of the referral made out to REACH and the referral explains what they need help with. However, through the assessment, we are able to dive in deeper and see what other existing problems the client may have and or are currently developing.
• Through the assessment that we are conducting, the clients are the ones who are verbalizing the issues they have. Once they identify the issue, they work with the social workers on developing a plan on what they need assistance with. Whether it’s applying for medical insurance, housing, food pantries, WIC, connecting with family and or friends for assistance and or obtaining supplies for a newborn. The social workers are not able to set any goals without the client’s involvement.
• I have no difficulties promoting client self-determination because the clients that I am serving are making decisions that are best suited for themselves and do not hinder others. The clients are looking for support to help them after being discharged from the hospital. If I come across a client making a bad decision, I will try to have the client find a way to express to me as to the decisions that they are making and why. I will then see if there are alternatives to the approach that they have taken and see how I might be able to support that. I will explore with the client’s other support members that might be able to intervene and assist in helping him/her make a better decision. If it comes to a point where the client is becoming harmful to themselves or others, I will notify my superiors and use the support from my supervisor as well as their guidance on what the next appropriate steps are needed to take. I will make sure I contact the appropriate authorities to help with the matter at hand.
• When it comes to measuring the client’s success in reaching their goals, I am not sure how exactly the agency measures the clients’ goals. However, the agency has a shared excel sheet of all resources and providers that they have used for their clients. When it comes to a client reaching their goals, prior to closing out a case, the social worker follows up with the client to see which goals have been met and the case needs to remain open a little longer so that they can help them reach some of those goals.
• The way I would use my client’s baseline to assess their progress/change is by following up with the clients and seeing where they are since the initial assessment and where they are now when concluding my relationship with the clients. Communicating with my clients is key in understanding in how much and or how far my client has come and what he/she is willing or not will not do to during these changes.

****During my internship, we took a tour at Second Harvest Food Bank on Mercy Dr. in Orlando. Besides how big and beautiful the place was, what the organization stands for was phenomenal and very inspiring. As I mentioned in one of my responses on measuring goals, my agency shares providers that have been helpful to our clients, and this is one. I feel that this organization/resource is not only beneficial for the clients that I have been working with but also for you ladies. Either it’s for the children in schools where Polly is and or clients who are inpatient at the hospital whom Alicia is working with. I love the fact that they have a program that it geared towards pregnant women and others for veterans, people who are homebound and or elderly. I could not attach the flyer, but here is the link. I am wanting to volunteer possibly for the holiday if anyone is interested, see below…**** https://www.feedhopenow.org/site/SPageServer/;jsessionid=00000000.app30130a?NONCE_TOKEN=419E43EC6D704487123AE8A6EC6D378A or Second Harvest Food Bank of Central Florida – Second Harvest Food Bank Of Central Florida (feedhopenow.org)

Elizabeth: I was not aware of the Reach Program until my internship. I think it is a great program as there are so many programs in the community   that many people are not aware of.  I have had the opportunity to send referrals to the Reach Program as part of my discharge planning.  I recall assessing a patient who needed assistance with paying his rent and I referred him to the Reach Program.  Many patients who are admitted to the hospital require help in addition to their medical needs. It’s a definitely a needed program, because it connects patients with advocates after they leave the hospital.   (Alicia Team 3)

Second Harvest is a great program that assist so many people. My son did his community service hours at Second Harvest.

Name: Alicia Henry

Agency: Orlando Health, Health Central 

The Social Worker at Orlando Health, Health Central Hospital, plays an important role in the discharge planning process to ensure that the patient’s needs are addressed and that everything is in place before the patient is discharged. The assessment process begins Prior to assessing the patient. The Social Workers view the patient’s chart, which contains the H&P (physical and history), current medications, support system, social deterrents, reason for admission, previous admission, DMEs (durable medical equipment), and insurance plan.  Knowing this information prior to assessing the patient can help to determine the best discharge plan. This is all part of the discharge planning process for each patient, which is known as the DCA (discharge assessment). These assessments are completed at the bedside with the patient, family member, POA, or guardian. If the patient is not alert or there is a no-contact order in effect, some assessments are conducted over the phone.

Orlando Health is a patient-focused facility. The DCA is done in order to include the patient in the discharge process. There is also a form (The Patients Choice) that must be discussed with each patient, informing them that they have the right to choose their own agencies and service providers. Although the patient has the right to select, what is approved is determined by the insurance plan.

Promoting self-determination is easy for me since I think that coming up with the best discharge plan is a shared goal. I just know a small portion of the patient’s life story. When it comes to what they will require after being released from the hospital, no one knows better than the patient. In a recent instance, the doctor recommended that the patient be sent to a skilled nursing facility (SNF) for rehabilitation. Despite living alone and having no one to help her, the patient desired to return home and receive in-home physical therapy. I informed the patient that because she lives alone, she will put herself at risk of falling.  I asked the patient why she didn’t want to go to a skilled nursing facility. She stated that she does not have anyone to care for her dog. I inquired as to who was looking after her dog while she was in the hospital. She stated a neighbor. I asked if I could contact her neighbor to see if her neighbor would care for the dog while she was in rehab. The patient agreed. I called the neighbor, who promised to look after the dog and also thought it was not a good idea for the patient to be at home alone while recovering.

Prior to the patient’s discharge, the goals are established and in place. I have observed that some Case Managers and Social Workers will follow up with patients who have been discharged home to ensure that any in-home services or equipment that were set up prior to discharge are in place.

Only patients with frequent admissions could have their baseline assessed. There is a patient who has 4 to 5 readmissions each month. This patient is non-compliant with his treatment and discharge plan. This patient makes excuses for not being able to complete necessary treatments due to a lack of transportation that was arranged prior to discharge. The hospital went out of its way to have a staff person travel to the patient’s residence to pick him up and take him to his

Faraz Rahman (Team 4) Response: Hi Alicia, As someone who has only just started getting involved with helping clients navigate how they can receive services through their insurance provider, I find the work that you are doing to be very helpful for your career as a social worker. At my agency, we are still working on making Medicaid an option for clients who are seeking services, but there are clients who do end up becoming disappointed because they would still be considered out of network at this point in time.

Alicia- That’s so great to hear that you helped your patient figure out a solution for her dog so that she can get proper care at a SNF! Someone else may not have taken the time to investigate further into her first decision to get physical therapy in her home, but you cared enough to do the extra work. -Polly

Name: Polly Smith

Agency: Seminole County Public Schools – Pine Crest Elementary

Lauren Frank (Team 1)- I love hearing about about your work with the school system! I would love to hear more. What are some other ways that you deal with difficult parents?

Hi Lauren- That’s a great question! My supervisor teaches me a lot about how she deals with difficult parents. When she makes calls to parents, she will sometimes introduce herself as the school social worker if she thinks that will help the interaction. Other times, she avoids mentioning her title on purpose. Some parents associate social workers with the fear of getting their children taken away, so mentioning her title might shut the conversation down. There are some parents who actually block the school’s phone numbers to avoid any type of confrontation or accountability. Since the school social worker is responsible for attendance/truancy, she will sometimes use her title as a way to show how important it is that caregivers get their children to school. Overall, my supervisor is able to skillfully deal with difficult parents by building rapport, establishing trust, and showing that she genuinely cares.

Elizabeth- I love Second Harvest!! They are a fantastic organization that does so much amazing work for the community. I still haven’t been to their main facility though in the 8 years I’ve lived here- I would love to go volunteer with you! I also love learning about the hospital setting from you and Alicia. I have no experience in this area so I’m trying to absorb as much as I can from you both, so thank you for sharing! -Polly

Polly- As Social Workers we always want what is best for the client. When dealing with adults who have the right to make their own decisions which may not always be the best decision, it can be really difficult to walk away knowing that they are not making a decision that would be beneficial for them. In the school system where all children are vulnerable and dependent on their parents or guardians to make the best decisions for them, it can be even harder to deal with when as the SW you are advocating for the best interests of the child and the parents have the final say. (Alicia Team 3)

Alicia- That’s exactly right! My supervisor brought up a great point about why she likes working with the middle school ages. She was saying that at the elementary grades, the students don’t question their parents’ choices. Often times parents train their children not to share information that could be concerning. But then as they get older and go to middle school, they start to question their parents and might rebel. In some cases, this developmental stage can help the children to break the cycle. The middle schoolers are more involved in making choices for their lives. I honestly had never thought about it that way, but it makes a lot of sense in communities like the one I’m interning at. That’s why I love this work- we all have different perspectives and can learn from one another!