1

Referral Process

• Referral Procedure
  • Medical staff and employees (via EMR, messenger, or phone)
  • Voluntary requests by patients or guardians
  • Community agencies (via phone or email)
• Eligible Clients
  • Patients with psychosocial, family, financial, or disability-related difficulties affecting treatment adaptation
  • Economically disadvantaged patients, the elderly, or persons with disabilities
  • Vulnerable groups (e.g., victims of child or elder abuse, sexual or domestic violence, single mothers, foreign nationals, etc.)
  • Patients needing counseling for discharge planning
  • Patients with chronic, rare, or life-threatening diseases, or those in crisis situations
  • Any patient facing significant personal or social hardship

2

Initial Interview

• Identify referred issues:
  • Psychosocial issues
  • Financial issues
  • Discharge issues
  • Community resource linkage
  • Rehabilitation issues
• Assess the patient’s personal background and socioeconomic status

3

Client Selection

Completion / Closure

• After the initial interview, determine whether intervention is necessary and decide on continuation or closure.

4

Problem Assessment

• Identify the client’s current issues and needs

5

Goal Setting

• Prioritize intervention areas
• Develop an intervention plan and methods

6

Intervention

• Methods of Intervention
  • Direct intervention by a social worker (emotional support, education, etc.)
  • Program connection (educational or group programs)
  • Volunteer service linkage
  • Community resource linkage (e.g., long-term care services, disability registration, welfare and assistive devices, medical expense support, referrals to community agencies, and other public services)
  • Other relevant service connections

7

Case Closure and Evaluation

• Evaluate outcomes based on intervention goals, then conclude or proceed with follow-up management.
• Referral to external agencies when necessary