Social Work Referral (Inpatient) 🤝
Guide for inpatient medical social work referral in the UK. Key information for discharge planning, domiciliary care, care home funding, NHS Continuing Healthcare, safeguarding, housing, and psychosocial support for resident doctors.
📋 Key Info to Have Ready
- Patient identifiers: name, DOB, NHS number / hospital number, ward and bed location
- Reason for referral, being specific: discharge supports, package of care, care home pathway, CHC checklist, housing/homelessness, carer strain, counselling, safeguarding, or benefits/finances
- Baseline living situation: lives alone or with others, house vs flat, stairs, heating, access to food and transport
- Current supports: family/friends, existing local-authority domiciliary care hours, district nursing, 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, lasting power of attorney or other decision-support arrangements, and whether collateral is available
- Practical barriers: no fixed address, rent/mortgage risk, benefits not in place, no transport home, caring responsibilities for children or dependants
- Safeguarding or welfare concerns (and whether already escalated to senior, adult safeguarding, children’s social care, or police)
- Urgency: safe for discharge today/tomorrow vs complex placement needing days to weeks
🔎 Common Reasons to Refer
- Complex discharge: needs a package of care, increased home support, equipment plus psychosocial planning, or uncertain destination
- Local authority Care Act assessment / domiciliary care (home care) while an inpatient, often via the discharge team or Discharge to Assess pathway
- Long-term care home pathway: local authority funding assessment, self-funding advice, or deferred payment agreement for care home fees
- Possible NHS Continuing Healthcare (CHC) or NHS-funded Nursing Care: flag to the discharge / CHC team early; full eligibility assessment is often done after acute recovery, not mid-crisis in hospital
- 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: Attendance Allowance / Universal Credit issues, 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 local children’s social care / police 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. package of care / care home pathway / CHC checklist / housing / family support / safeguarding advice].
- At baseline they [lived alone / with family] in [housing type], with [supports, e.g. no formal home care / X hours domiciliary care]. 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 / care 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 or the discharge team directly if discharge is imminent or if there is an urgent safeguarding concern.
📝 Tips
- Refer early. Packages of care, care home placements, and CHC processes take time; last-minute referrals delay discharge.
- Be specific about the ask (e.g. "needs Care Act assessment 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.
- Know your local discharge model (often Discharge to Assess / pathway 0–3). Long-term funding decisions are frequently completed after leaving the acute bed.
- NHS Continuing Healthcare is NHS-funded care for people with a primary health need. It is not the same as local-authority care home funding. Incomplete checklists and missing collateral are common delays.
- Local authority care home funding and deferred payment agreements are means-tested under the Care Act (England) or equivalent devolved rules. Incomplete financial documents delay placement.
- Safeguarding and child protection: escalate same day via local policy (senior, adult safeguarding lead, children’s social care, police out of hours). Do not wait for a routine MSW slot if the person is at immediate risk.
- Document capacity and any lasting power of attorney or best-interest process 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.
- Pathways differ by Trust, ICB, and UK nation. Confirm local discharge, CHC, and safeguarding SOPs.
Related NICE guidance
NICENICE NG27 — Transition between inpatient hospital settings and community or care home settings for adults with social care needs (Dec 2015)
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Educational reference only. Medical disclaimer