Social Services
Medical social work, case management, and connection to community resources.
What is Social Services?
Medical social workers help patients and families navigate the complex healthcare system, access community resources, plan for long-term care needs, and address psychosocial challenges. They are an integral part of the care team.
Patient Path Hub coordinates medical social services for patients in hospitals, skilled nursing facilities, and at home. Our social workers help with discharge planning, insurance navigation, advance directives, and connecting to community resources.
Who Social Services is for
This type of care is recommended for patients who meet the following criteria. Our coordinators can help determine eligibility based on your specific situation.
- Patient is facing a healthcare transition or complex psychosocial situation
- Patient or family needs help navigating community resources
- Physician has ordered social work services
- Patient is in a hospital, SNF, or home health episode
Benefits of Social Services
How this service supports better outcomes, comfort, and peace of mind for patients and families.
Discharge Planning
Smooth transitions from hospital to home or facility.
Resource Connection
Link to community programs, financial assistance, and support.
Advance Directives
Help with healthcare powers of attorney and living wills.
Guidance for families
Making care decisions can feel overwhelming. Here’s what to keep in mind when considering social services.
Ask about insurance coverage
Medicare, Medi-Cal, and many private plans cover social services, but coverage details vary. Our coordinators can help you understand what your plan may cover before care begins.
Prepare questions in advance
Before meeting with a provider, write down your questions about the care plan, schedule, what to expect, and how to reach the care team. Our coordinators can help you build this list.
You’re not alone in this
Patient Path Hub stays involved throughout the care transition — we’re here to answer questions, address concerns, and help adjust the care plan as needs change.
Frequently Asked Questions
Common questions about social services coordination through Patient Path Hub.
What does a medical social worker do?
Medical social workers help with discharge planning, counseling, resource connection, advance directives, and psychosocial support.
Can social workers help with financial assistance?
Yes. They can help patients apply for Medi-Cal, Social Security disability, prescription assistance, and other programs.
Is social work covered by insurance?
Medical social work is covered by Medicare and most insurance plans when part of a home health or hospice episode.
Can you help with advance directives?
Yes. Social workers help patients complete advance directives, healthcare powers of attorney, and POLST forms.
What if my loved one is in the hospital?
Hospital social workers are key team members — request to speak with one during your stay, and we'll coordinate on your behalf.
Related Services
Patients who need social services may also benefit from these coordinated services.
Community Resources
Connection to local support programs, financial assistance, transportation, food, and housing resources.
Learn moreBehavioral Health
Mental health and counseling support for patients and families facing serious illness or life transitions.
Learn moreHospice
Compassionate end-of-life care focused on comfort, dignity, and quality of life for patients and families.
Learn moreHome Health
Skilled nursing, therapy, and support delivered safely at home after illness, injury, or hospitalization.
Learn moreReady to request Social Services?
Our care coordinators are here to help you navigate next steps. Submit a referral or talk with us directly.