title: "When Things Are Really Complicated, We Call the Social Worker": Post-Hip-Fracture Care Transitions for Older People.
abstract: Social workers play a key role in the delivery of interdisciplinary health care. However, in the past decade, concerns have been raised about social work's sustainability and contributions in a changing health care sector. These changes come at a time when older patients are more complex and vulnerable than ever before. In this article, using a strengths-based approach, the authors examine the key contributions made by social workers working with older patients with hip fracture as they strive to achieve successful care transitions. Twenty-five interviews with health care professionals (HCPs) were conducted and then analyzed using an analytical coding framework. Although social workers are vital, they are often underused and overlooked in the care of hip fracture patients. The authors sketch the important contributions that social workers make to care transitions after hip fracture, specifically informational continuity; patient-HCP relational continuity; conflict resolution; mediation among family, patient, and HCP (for example, doctors and nurses); collaboration with family caregivers and community supports; and relocation counseling.
authors.forename: Joanie
authors.initials: J
authors.lastname: Sims-Gould
authors.forename: Kerry
authors.initials: K
authors.lastname: Byrne
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Hicks
authors.forename: Thea
authors.initials: T
authors.lastname: Franke
authors.forename: Paul
authors.initials: P
authors.lastname: Stolee
mesh_terms: D001291:Attitude of Health Personnel; D017028:Caregivers; D003266:Continuity of Patient Care / Q000458:organization & administration; D003299:Cooperative Behavior; D005190:Family; D006620:Hip Fractures / Q000628:therapy*; D006801:Humans; D017008:Negotiating; D010348:Patient Care Team / Q000458:organization & administration; D024382:Professional Role; D012720:Severity of Illness Index; D000068217:Social Workers; D000069341:Transitional Care / Q000458:organization & administration*