Continuing Care at The Queen’s Medical Center – West O‘ahu

Care Assessment

Upon being admitted, our Social Workers provide an initial screening and evaluation of high-risk patients and families. The team will conduct a brief assessment for newly diagnosed patients and their families encompassing crisis intervention and counseling for dealing with grief, substance abuse counseling, and chronic illnesses.

Continuity of Care

Our Continuing Care and social workers help patients and families understand an illness diagnosis and treatment options. We can ease your adjustment to hospital admission, assess the possible role changes within a family and help explore the emotional and/or social responses to an illness diagnosis and the treatment plan.

We also educate patients on Physician Orders for Life-Sustaining Treatment (POLST) and advance health care directives. Our goal is to empower patients and families to communicate with each other and members of their health care team to facilitate constructive decision making for overall wellness.

Discharge Coordination and Community Resources

The Continuing Care team coordinates discharge planning for patients and families. Our social workers can facilitate arrangements for nursing home or care home placement, facility transfers, outpatient home care, community resources, and outpatient follow-up referrals. Every effort will be made to procure placement, if necessary. When a patient’s level of care has been lowered to less than acute, they will be discharged from the hospital within three days of the notification. If there is no available placement, the patient will be discharged home. This is necessary to allow for acute care services of the hospital to be made available to other patients needing treatment.