Medical Social Work Discharge Coordination / 医疗社工与出院衔接

Medical social work discharge coordination is the hospital-to-life bridge described by [[QiongQiong|琼琼]] in 147.再谈日本医疗与照护行业之我曾在北海道的医院当护士. In the Japanese hospital setting she observed, medical social workers helped coordinate discharge destinations, long-term care services, welfare systems, public assistance, institutional placement, and home support.

The concept matters because hospital discharge is not purely a medical endpoint. A patient who cannot safely return home may need care certification, rehabilitation, social welfare, transport, family negotiation, facility availability, or public support. Without that bridge, hospitals can drift back toward Social Hospitalization / 社会性住院 or families can become the default case manager.

Key Claims

• Discharge is a care-system task, not only a doctor signing a patient out.
• Social work can reduce the coordination burden on families, doctors, and nurses.
• Older or disabled patients need linkage across medical care, welfare, long-term care, housing, and daily support.
• The role is especially important in Japanese No-Family-Attendant Care / 日本无家属陪护 because hospital care is already less dependent on family bedside labor.

Connections

• Community Integrated Care / 社区综合照护, Aging-In-Place Support System / 居家养老支持系统, and Elder Care State Capacity - system context.
• Social Hospitalization / 社会性住院 - problem that discharge coordination can reduce.
• Long-Term Care Insurance Planning - care-financing and service-access branch.
• Multidisciplinary Hospital Care / 医院多职种协作 - team setting where social workers operate.
• Care Socialization / 照护社会化 - broader transfer of care work from private family improvisation to organized roles.