Using the Eco-Map and Ecosystems Perspective to Guide Skilled Nursing Facility Discharge Planning.

Area of Science:

• Gerontology
• Social Work
• Healthcare Management

Background:

• Increasing numbers of older adults require skilled nursing facility (SNF) care after hospitalization in the U.S.
• Approximately 20% of Medicare beneficiaries are admitted to SNFs post-hospital stay.
• Discharge planning is a critical phase in care transitions, especially for seniors.

Purpose of the Study:

• To present the ecosystems perspective and eco-map as tools for social workers in discharge planning.
• To enhance the examination of patient-system transactional relationships.
• To facilitate the provision of comprehensive wrap-around services for patients upon discharge.

Main Methods:

• Utilizing the ecosystems perspective to analyze patient environments.
• Employing the eco-map tool to visualize social relationships and support systems.
• Focusing on social workers' role in assessing psychosocial factors during care transitions.

Main Results:

• The ecosystems perspective allows for a holistic view of patient needs.
• The eco-map visually represents patient's social networks and resource accessibility.
• These tools aid social workers in identifying gaps in support and planning interventions.

Conclusions:

• The ecosystems perspective and eco-map are valuable tools for social workers in SNF discharge planning.
• These approaches can lead to more effective identification and coordination of wrap-around services.
• Improved discharge planning can enhance patient outcomes and transitions to post-acute care settings.