The Social Worker in The Care of The Stroke Patient

Abstract

As a leading cause of death and long-term disability, stroke care is a complex endeavor, requiring a coalition of healthcare professionals. As part of a multi-disciplinary team, social workers help the patient to reach individual goals and facilitate their return to and stability in their community at their highest possible functional, social, and economic level.

Full text

Doi: 10.32481/djph.2023.08.009
The Social Worker in The Care of The Stroke Patient
Annamarie McDermott, LMSW, ACM-SW
Director, Care Management and Social Work, Saint Francis Hospital
Abstract
As a leading cause of death and long-term disability, stroke care is a complex endeavor,
requiring a coalition of healthcare professionals. As part of a multi-disciplinary team, social
workers help the patient to reach individual goals and facilitate their return to and stability in
their community at their highest possible functional, social, and economic level.
Stroke is one of the most stressful, life changing experiences for a person. No one plans for them.
They are always an emergency that in some way upends life as it was. Given that stroke is a
leading cause of both death and disability in the United States, providing care to a person with a
stroke is a complex endeavor, requiring a coalition of healthcare professionals. The social worker
is an active member of a stroke patient’s care team, helping the patient to reach individual goals
and facilitate the patient’s return to and stability in their community at their highest possible
functional, social, and economic level.
To understand the contributions of a social worker to the stroke recovery care team, it is
important to have a brief overview of who social workers are and what they do. The National
Association of Social Workers characterizes social work as a helping profession focused on
helping individuals, families, and groups restore or enhance their capacities for social
functioning and work to foster a supportive community.1 The practice of social work requires
knowledge of human development and behavior; of social, economic, and cultural institutions;
and of the interaction of all these factors. They work in every area of community life - schools,
hospitals, mental health clinics, senior centers, elected office, private practices, prisons, military,
corporations, and in numerous other public and private agencies that serve individuals and
families.
Social workers, both at the bachelor’s and master’s level licensures, are required to continue their
education. Since social workers are in a diversity of settings, they must seek opportunities to
educate themselves on the particulars of that setting. To effectively listen, communicate, and
advocate as a stroke care social worker, an essential knowledge of stroke is imperative. Both the
American Stroke Association (ASA) and the American Heart Association (AHA) have an
extensive education library specifically for professionals.2 More locally, the Medical Society of
Delaware and the Delaware Stroke Initiative offers numerous education opportunities.3 Of note,
the John Scholz Stroke Education Conference has been held annually with speakers and topics
from the multiple disciplines who care for stroke patients, with 2022 forum presentations
available online as of this writing.4
Interventions
Social workers offer a broad scope of interventions that can assist the multi-disciplinary team in
best care for the stroke patient. Below are some key roles and responsibilities of social workers
on a stroke team, applicable at all levels of care.

Doi: 10.32481/djph.2023.08.009
Emotional Support
Stroke can have a profound impact on a patient’s well-being, their lifestyle, their ability to
manage responsibilities like work, finances, and even seemingly mundane tasks like housework
and meal preparation. Social workers offer emotional support to stroke survivors and their
families, to help navigate the complex emotions of fear, grief and worry that may arise after a
stroke. For a stroke survivor with pervasive deficits, or even one debilitating deficit, adjustment
to living with disability often involves going through a grief process. Caregivers of stroke
survivors are at risk for developing burnout, a condition that can cause physical and mental
exhaustion, anxiety, and depression. While every discipline on a stroke care team is attuned to
these issues, the role of the social worker is suited to create time for purposeful engagement with
their patient and families on the emotional experiences and reactions to stroke.
Mental Health Referrals
As a stroke interrupts the blood supply to the brain, this “brain attack” can cause emotional and
behavioral changes, depending on which part of the brain is affected and the extensiveness of
injury. Forgetfulness, carelessness, confusion, as well as anxiety, anger, or depression can be
experienced. Post-stroke depression can affect approximately one third of stroke survivors,
increasing risk for suboptimal recovery, recurrent vascular events, poor quality of life, and
mortality.5 When parts of the brain that control emotions are injured by a stroke, some people
experience pseudobulbar affect (PBA), also called emotional lability or reflex crying.6
Uncontrollable laughter and sudden mood shifts are also symptomatic of PBA. It is imperative
that a social worker caring for a stroke survivor be attuned to that person’s mental health needs.
Social workers can provide psychosocial support and, importantly, facilitate communication to
the stroke survivor’s medical team and make appropriate referrals.
Care Coordination
Social workers help coordinate various aspect of a stroke patient’s care, including planning for
discharge from 24-hour care facilities to lower levels of care, and facilitating communication
among health care professionals. Social workers use their advocacy skills to assist patients in
accessing healthcare resources, insurance coverage, and financial assistance programs. They are
often tasked with ensuring a stroke survivor has appropriate durable medical equipment, such as
a walker or hospital bed. Another important task is ensuring medication assess. Stroke survivors
may be prescribed medications to manage medical conditions that contributed to the stroke and,
vitally, reduce risk of stroke recurrence. Some of these medications, like brand name anti-
coagulants, can be quite expensive. Ensuring financial coverage, which may include managing
prior authorizations, is essential.
Community Resources
Whereas care coordination is a more structured process, usually involving coordination with
health care providers and with the patient’s insurance, social workers also connect patients and
their families with support groups, educational resources, and social assistance programs to
promote a successful transition back to their community. The Delaware Stroke Initiative has
employed both in person and remote support groups.7 To help address needs like housing, food,
transportation, and other such essential requirements, Delaware’s 2-1-1 is a free confidential

Doi: 10.32481/djph.2023.08.009
service that connects people in the State of Delaware with health and human services to support
individuals and families in need.8
Social Determinants of Health
As the guide for national health promotion and disease prevention under the U.S. Department of
Health and Social Services, Healthy People 2030 promotes a society in which all people can
achieve their full potential for health and well-being across the lifespan.9 A powerful tool in
building this vision is identifying and addressing the Social Determinants of Health, conditions
where people are born, live, learn, work, play, and age that affect a wide range of health,
functioning, and quality of life outcomes and risks.10 Inherent in the role and function of a social
worker, as charged by the principles of service and social justice in the National Association of
Social Worker’s Code of Ethics, the social worker – as member of a stroke survivor’s care team
– must identify the impact of non-medical issues on a stroke patient’s progression of care.
Factors like housing, transportation, access to nutritious foods and exercise, as well as a plethora
of non-medical factors may contribute to causing a primary or recurrent stroke. While an
intimidating task seemingly beyond the abilities of one medical social worker in a healthcare
setting, Healthy People 2030 has a strong emphasis on data driven research and collaborative
partnerships. Both acute care and the outpatient setting have medical codes specific to social
determinants of health. As part of the care team, social workers should be purposeful not only in
addressing patient specific issues to the best of their professional abilities, but also in ensuring
accurate documentation of these determinants.
Vulnerable Populations
In healthcare, the designation of vulnerable population is simultaneously broad and specific.
Broadly, it refers to individuals who have poor access to healthcare and experience poor
outcomes as the result of factors such as age, geographic location, language, gender or sexual
orientation, chronic illness or disability, race, and economic status. Sometimes, depending on a
host of interplaying factors, specific populations are more vulnerable than others, such as persons
in congregate care settings during the COVID pandemic.
Due to the elevated risk of disability and mortality, particularly among individuals with a history
of stroke, social workers have a crucial responsibility to diligently identify individuals at risk of
not receiving preventive care. One of the most vulnerable populations is the uninsured.
Assessment and stabilization of all persons in an emergency medical situation, regardless of
insurance coverage or ability to pay, is safeguarded by the federal Emergency Medical Treatment
& Labor Act (EMTALA). For many stroke patients, stabilization is just the beginning. An
uninsured person may not have access to much needed post hospital care, like medications and
rehabilitative services. A well-informed social worker should readily be aware of healthcare
clinics and financial assistance programs, and facilitate completion of applications and making
referrals.
Another vulnerable population is the socially isolated. As recently articulated by the U.S.
Surgeon General, loneliness is associated with a greater risk of cardiovascular disease, dementia,
stroke, depression, anxiety, and premature death.11 The AHA provides a sharper focus of the
impact of loneliness on stroke, reporting that socially isolated adults with three or fewer social
contacts per month may have a 40% increased risk of recurrent stroke or heart attack.12
Discharge planning back to the community – particularly if the person is impacted by stroke

Doi: 10.32481/djph.2023.08.009
deficits – can be challenging. Loneliness and social isolation can be well hidden, so a purposeful
conversation is worthwhile. For a formal assessment, the Lubben Social Network Scale is a brief
instrument that gauges social isolation in older adults by measuring perceived social support
received by family and friends.13
Of note, technological literacy has become a recent stressor for patients in managing their health.
Technologies supporting care coordination and patient engagement can serve as a bridge, rather
than a barrier, only when barriers are directly remedied. Issues include lack of internet access,
lack of a phone, lack of an appropriate device, cost concerns, lack of training for the individuals
and their family members on how to use the tools, and language barrier issues.
Stroke care is not only best provided by a multidisciplinary team, but also across a continuum of
care. Stroke care usually begins in the community with 911 and first responders and ideally ends
in the community, as the stroke survivor transitions back to their home.
Social Work During Acute Hospital Care of a Stroke Patient
This phase of care, beginning with the arrival of the ambulance and proceeding through the
Emergency Department and continued hospitalization, is the busiest, most stressful, and
uncertain phase for a stroke patient and their loved ones. The medical team is focused on
accurate diagnosis, treatment, and stabilization. During this stabilize and treat phase, the hospital
social worker focuses on family engagement, coordinating family meetings with the medical
team, and addressing needs and concerns as brought up by the patient and their families.
The discharge planning process happens concurrent to stabilize and treat. While “discharge
planning starts at the door” is a standard for hospitals, it is an overwhelming thought for a patient
and their family to even think about during such a crisis. The hospital social worker, sometimes
with a nurse care management partner, is tasked with educating patients and their families on its
necessity. Discharge plans for life changing conditions like stroke often take time as they have a
multitude of variables.
From the hospital, the ASA strongly recommends the Inpatient Rehabilitation Facility (IRF)
level of care for stroke survivors who can manage three hours of therapy daily.14 Other options
for care include skilled nursing facilities (SNFs), appropriate for those whose nursing needs are
more significant than rehabilitation needs and patients can only tolerate an hour daily of
therapies. Long term acute care (LTAC) is specifically for stroke survivors with serious medical
conditions that require ongoing care but no longer require intensive care or extensive diagnostic
procedures.
For stroke survivors leaving acute care with minimal to no deficits, homecare is an option, which
can provide skilled nursing, physical, occupational and speech therapies, and social work. Some
stroke survivors can be managed safely with outpatient follow up. In these cases, it is imperative
that the discharge planner, often a social worker, ensure follow up appointments as
recommended by the care team, usually neurology, cardiology, and primary care. Of equal
importance is ensuring the stroke survivor has access to prescribed medications.
Social Work During Post-Acute Facility Care of a Stroke Patient
Stroke deficits can be pervasive, impacting a multitude of functions: gross motor skills, fine
motor skills, speech and language, cognition, vision, and emotions. Appropriate, quality

Doi: 10.32481/djph.2023.08.009
rehabilitation with specially trained therapists is necessary for the best possible recovery. Rehab
therapies usually begin in the hospital setting once physicians have cleared the patient medically.
It is vital that a stroke survivor with deficits transition to the next level of rehabilitative care as
soon as possible. As hospital level of care is ideally brief and focused on medical stabilization,
hospital therapy sessions are comparatively brief and focused on assessment of the stroke
survivor’s deficits and subsequent discharge needs.
The ASA estimates that 10% of people fully recover from a stroke, 25% have only minor
impairments and 40% have moderate impairments that are manageable with some special care.
The sooner a stroke survivor starts a therapy program, the more likely they are to regain
impacted abilities and skills.14
In the IRF level of care, therapists in collaboration with a physician specially trained in
rehabilitative medicine provide comprehensive interventions. A stroke survivor’s IRF care team
is focused on the prevention of secondary complications, treatment to reduce neurological
deficits, and compensation to adapt to disabilities that may continue over an indefinite time. The
IRF social worker’s role and function is similar to the acute hospital social worker, with
heightened focus on return to the community and post-facility adjustment. The IRF care team
relies heavily on social work to facilitate a safe discharge to home, the preferred discharge goal
after extensive rehabilitation is completed.
Stroke survivors who step down from the hospital to a SNF usually have skilled nursing needs
that take precedence over rehabilitation needs. Likely, they are unable to tolerate three hours of
daily therapy, which is often related to previous level of functioning, extensiveness of the stroke,
or the interplay of the stroke with comorbidities. Social workers in the SNF level of care carry a
breadth of responsibilities. They facilitate the admission process, assist in creating a
comprehensive plan of care, perform needs assessments, and plan for discharge. A SNF social
worker will manage discharge plans to IRF, to the home, or transition a patient to long term care
in a nursing home.
Stroke survivors who discharge from the hospital to the LTAC setting have serious medical
conditions that require ongoing care, but no longer require intensive care or extensive diagnostic
procedures. They may then transition to IRF, SNF or even home.
The focus of stroke care and medical care in general is to restore a person’s health and wellbeing.
Some strokes are so profound that they cause irreparable damage. Hospice can be the right
support for certain stroke patients. The hospital social worker can facilitate goals of care
conversations and ensure referrals are made to the agency that can best care for a patient and
their family at this most critical point. Hospice social workers then continue to offer support,
whether it is counseling or resource finding.
Discharge Planning from Facility Level of Care
As levels of medical care that treat stroke, hospitals, IRFs, SNFs and LTACs have the common
thread of being 24-hour care facilities with medical supervision and access to highly trained
healthcare professionals. Discharge planning from each level of care, whether it is to another 24-
hour care facility or to home, mandates effective needs assessments. Discharge planning tools
guide the discharge planner and their team in well-informed decision making about the stroke
survivor’s needs, and how to provide the most appropriate care possible.

Doi: 10.32481/djph.2023.08.009
There are several discharge planning models to guide social workers and their fellow clinicians,
all with the shared goal of transitioning the patient out of facility care safely and effectively.
IDEAL (Include, Discuss, Educate, Assess, Listen) focuses on engaging patients and family
members. RED (Re-Engineered Discharge) focuses on actions the hospital undertakes during and
after the hospital stay to ensure a smooth and effective transition at discharge, making follow up
appointments, identifying discharge medications and planning how patients can obtain them. The
Agency for the Healthcare Research and Quality, under the U.S. Department of Health and
Human Services, has toolkits for both initiatives.15,16 Better Outcomes for Older Adults through
Safe Transitions (BOOST), emphasizes teach back and capturing discharge information on a
readable one-page document.17 An integrated and pragmatic approach that is informed by
research and evidence from sources like the above three approaches can help guide a
comprehensive discharge plan individualized to the patient.
Social Work During the Outpatient Phase of Stroke Patients
At this point in the recovery process, social workers are focused on the stroke survivor’s
adjustment back to their home and community, arguably the most important transition.
Depending on the severity of the stroke, pervasiveness of any deficits, and impact of medical
comorbidities, it could last weeks to months after a stroke survivor arrives home. For others, it
can be a couple of days, as may be case with a TIA. In the initial three months after a stroke, the
risk of stroke is 15 times higher than the general population. Furthermore, the ASA estimates
that 23% of strokes are recurrent. Clearly, attention to this transition is crucial.
In the outpatient setting, the stroke survivor may access a social worker through a home care
agency who is also providing skilled nursing and therapy services. Social work may also be
available if the primary care physician or other involved provider is part of an accountable care
organization (ACO). An ACO care coordinator will reach out to a stroke survivor to ensure they
are aware of the supports offered by the ACO team. Social work is also available if the patient is
undergoing cancer treatment or getting hemodialysis.
Generally, the outpatient social worker will build on the successful discharge planning from
previous levels of care. If there are issues with availability of prescribed medications, durable
medical equipment, or expected healthcare services, a social worker is helpful in navigating
these issues to resolution. Social workers will provide both education and counselling for the
patient and their families to assist them in processing the realities of the stroke event and its
aftermath. The social worker can also focus on social supports such as finding social self-help
groups within the community. The outpatient social worker uses their own critical thinking, input
from the medical care team, and feedback from the stroke survivor to identify and address, as
best possible, barriers to the stroke survivor’s stability within their own community. Of perhaps
even greater value is the work an outpatient social worker does that contributes to stroke
prevention – access to medications, screenings, and medical transportation, to name a few.
Conclusion
Strokes are one of the most stressful, life changing things a person will ever experience. No one
plans for them. Compassionate patient centered care goes a long way to alleviate that stress and
get the patient on their road to recovery. Social workers can be helpful at all stages of patient
stroke recovery and are a vital resource to the care team and to the patient.

Doi: 10.32481/djph.2023.08.009
Ms. McDermott may be contacted at amcdermott@che-east.org.
References
1. National Association of Social Workers. (n.d.). About social workers.
https://www.socialworkers.org/News/Facts/Social-Workers
2. American Stroke Association. (n.d.). Professionals. [REMOVED HYPERLINK
FIELD]https://www.stroke.org/en/professionals
3. Delaware Stroke Resources. (n.d.). Stroke education.
https://delawarestrokeresources.org/?page_id=398
4. Delaware Academy of Medicine/Delaware Public Health Association. (2022). 2022 Scholz
stroke education conference. https://delamed.org/education/educational-
series/conferences/2022-scholz-stroke-education-conference/
5. Towfighi, A., Ovbiagele, B., El Husseini, N., Hackett, M. L., Jorge, R. E., Kissela, B. M., . .
. Williams, L. S. (2017, February). Poststroke depression: A scientific statement for
healthcare professionals from the American Heart Association/American Stroke
Association. Stroke, 48(2), e30–e43. https://doi.org/10.1161/STR.0000000000000113
PubMed
6. American Stroke Association. (2018, Nov). Pseudobulbar affect (PBA).
https://www.stroke.org/en/about-stroke/effects-of-stroke/emotional-effects-of-
stroke/pseudobulbar-affect
7. Delaware Stroke Resources. (n.d.). Delaware support groups.
https://delawarestrokeresources.org/?page_id=337
8. 2-1-1 Delaware. (n.d.). Help starts here. https://delaware211.org/
9. United States Department of Health and Human Services. (n.d.). Healthy people 2030:
Building a healthier future for all. https://health.gov/healthypeople
10. United States Department of Health and Human Services. (n.d.). Social determinants of
health. https://health.gov/healthypeople/priority-areas/social-determinants-health
11. Office of the U.S. Surgeon General. (2023). Our epidemic of loneliness and isolation: The
U.S. Surgeon General’s Advisory on the healing effects of social connection and
community. https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-
advisory.pdf
12. Cené, C. W., Beckie, T. M., Sims, M., Suglia, S. F., Aggarwal, B., Moise, N., . . .
McCullough, L. D. (2022, August 16). Effects of objective and perceived social isolation on
cardiovascular and brain health: A scientific statement from the American Heart
Association. Journal of the American Heart Association, 11(16), e026493.
https://doi.org/10.1161/JAHA.122.026493 PubMed
13. Brandeis University. (n.d.). Lubben social network scale.
https://www.brandeis.edu/roybal/docs/LSNS_website_PDF.pdf
14. Winstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C., . . . Zorowitz,
R. D. (2016, June). Guidelines for adult stroke rehabilitation and recovery: A guideline for

Doi: 10.32481/djph.2023.08.009
healthcare professionals from the American Heart Association/American Stroke
Association. Stroke, 47(6), e98–e169. https://doi.org/10.1161/STR.0000000000000098
PubMed
15. Agency for Healthcare Research and Quality. (2017, Dec). Care transitions from hospital to
home: IDEAL discharge planning. https://www.ahrq.gov/patient-safety/patients-
families/engagingfamilies/strategy4/index.html
16. Agency for Healthcare Research and Quality. (2023, Apr). Re-engineered discharge (RED)
toolkit. https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html
17. Coffey, C., Greenwald, J., Budnitz, T., & Williams, M. V. (2013). Project BOOST
implementation guide, 2nd Ed. Society of Hospital Medicine.
https://www.hospitalmedicine.org/globalassets/professional-development/professional-dev-
pdf/boost-guide-second-edition.pdf
Copyright (c) 2023 Delaware Academy of Medicine / Delaware Public Health Association.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(https://creativecommons.org/licenses/by-nc-nd/4.0/) which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.