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Our In-Home Services & Support | HomeHealth - ChristianaCare
Medical Social Workers Supporting You & Your Family
Simple, caring support to help you manage at home.
Medical social workers help you and your caregiver manage life at home – connecting you to resources, benefits, counseling and safety planning. If you're receiving skilled home health care, Medicare may cover these services.
Start with a referral or call us at 888-862-0001 to check your eligibility.
What a Medical Social Worker Does
ChristianaCare medical social workers (MSW) supports patients and families as they navigate the emotional, social and practical challenges of receiving care at home.
- Emotional support: Talk through stress, illness or big life changes.
- Find helpful services: Connect you to medical social services at home and local programs and resources like meals, rides or financial help.
- Caregiver support: Offer tips, planning help and respite options to ease caregiver stress.
- Help with benefits: Explain and help you apply for Medicare, Medicaid or supplemental security income.
- Plan ahead: Help you share your wishes and complete forms like advance directives.
- Home safety: Spot risks (like falls) and suggest ways to make your home safer.
- Remove barriers: Help with issues like food, cost, transportation or limited support.
Care follows trusted standards from the National Association of Social Workers (NASW).
Is Medical Social Work Covered by Insurance?
Medical social work is often covered as part of a home health care plan, but coverage depends on your insurance and whether you meet eligibility requirements.
To receive home health services under Medicare, patients must meet two key requirements:
- Homebound eligibility: Leaving home is difficult and usually requires assistance from another person, a mobility device or special transportation. Patients may still leave home for medical appointments or short, infrequent outings.
- Skilled care need: A provider has ordered part-time skilled care from a licensed clinician such as skilled nursing, physical therapy, occupational therapy or speech-language pathology.
When these conditions are met, medical social work services may be covered as part of your home health care plan.
What Medicare typically covers:
- Support with coping and adjustment during illness or recovery
- Help connecting to community resources and benefits
- Caregiver support and planning assistance
- Guidance for advance care planning
- Assistance with safe transitions and discharge planning at home
Medical social work is provided as part of a coordinated care team alongside nurses, therapists and home health aides.
Important coverage notes:
Insurance Type | Coverage for Medical Social Work |
Medicare | Covered when homebound and skilled-care eligibility requirements are met |
Medicaid only | Medical social work is not billable |
Medicare + Medicaid | Covered when Medicare home health eligibility requirements are met |
Most private insurance plans | Generally covered, depending on plan benefits and authorization requirements |
Medical social services are not provided as a standalone service. They are only covered when there is also a qualifying skilled medical need as part of the overall home health care plan.
For questions about coverage, costs or billing, you can learn more here.
Coverage follows guidance from Medicare and the Medicare Home Health Benefit Policy Manual.
How Referrals & Care Transitions Work
After a hospital stay, your hospital discharge social worker or care team helps arrange services so you can return home safely. If home health is right for you, your clinician sends a referral and orders the services you need.
What to expect:
- Referral & orders: Your doctor or hospital team requests home health services and outlines your needs (including nursing, therapy and medical social services). You can also learn more about hospital-based care options like hospital care at home.
- Start of care: A home health clinician contacts you (often within 24 hours) to schedule your first visit.
- Care plan: Your team creates a simple plan with your goals, services, visit schedule and safety steps.
- Care transition support: A medical social worker helps you and your caregiver understand the plan, connect to resources and prepare for daily life at home.
- Ongoing communication: Your home health team stays in touch with your doctor, updates your plan as needed and answers questions along the way.
This approach follows best practices from the Agency for Healthcare Research and Quality. It means your care team will include you and your family, explain what to expect, provide easy-to-understand guidance, ensure everything is clear and listen to your needs and goals.
Common Needs Medical Social Workers Solve
Medical social workers help address everyday challenges that can affect your health and recovery at home.
- Transportation: Help with arranging riders to medical appointments or treatments.
- Food access: Connect you to meal programs or grocery support if cooking or shopping is difficult.
- Caregiver burnout: Support caregivers with education, planning and options for respite or extra help at home.
- Housing and utilities: Link you to programs for housing stability or assistance with utility bills.
- Behavioral health support: Connect you with counseling, mental health services and supportive care options like palliative care when needed.
- Safety risks at home: Identify concerns like fall risks, isolation or unsafe living conditions and help create a plan to improve safety.
For example, if a patient is struggling to get to follow-up appointments after a surgery, a social worker may arrange transportation and check in on other support needs. Medical social workers also help link patients to appropriate health coverage and benefits. When patients lack quality supplement coverage or are uninsured, medical social workers can help them apply for subsidized Medical Assistance or purchase supplement coverage to ensure bills get paid in full.
What to Expect at Your Visit
During your visit, a medical social worker completes a social work assessment to better understand your needs at home. This includes talking with you about your health, daily routine, support system and challenges you or your caregiver may be facing.
They will help you set simple, realistic goals like improving safety at home, reducing stress or connecting to community support.
Next, they create a personalized care plan that may include resources such as transportation, meal programs, financial assistance or counseling services. They will also explain what support is available and help you access it.
Follow-up visits or check-ins depend on your needs and are coordinated with your overall home health team.
Get Started
Getting help from a home health social worker is easy. You can call us or fill out a secure online form. If your doctor has a referral, you can upload it through our secure system.
Once we receive your request, we usually respond within 24–48 hours to talk about next steps and check eligibility.
We'll also confirm if we serve your area and help coordinate your care with your doctor.
Spanish-speaking support is available so you can get help in the language you're most comfortable with.
If you're searching for medical social workers near me, we're here to help you get connected quickly and support your care at home.
Frequently Asked Questions
A home health medical social worker helps you and your family manage the non-medical parts of care at home. This includes emotional support, counseling and helping you find community resources like transportation, meals, housing support or financial assistance. They also help with care planning, safety at home and connecting you to services that reduce stress for both patients and caregivers.
Yes – Medicare may cover medical social services at home, but only when you also qualify for home health care. This means you must be homebound and need part-time skilled care like nursing or therapy ordered by your doctor. When those conditions are met, a medical social worker can be part of your covered home health team.
After discharge, your hospital team or doctor sends a referral for home health if you qualify. A care coordinator or social worker helps arrange services, shares your care needs with the home health team and sets up your first visit (usually within 24–48 hours). This helps make your transition from hospital to home safer and smoother.
Contact Us
New Castle County Office
Kent and Sussex County Office
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