The role of medical social workers in discharge conferences at acute care hospitals

In Japan, healthcare reforms aimed at establishing a sustainable social security system have promoted functional differentiation of hospitals and shorter lengths of stay, requiring patients to return home earlier than previously. In acute care hospitals, discharge conferences play a crucial role in supporting older adults with care needs, ensuring smooth transitions from hospital treatment to home care, and building reciprocal collaboration with community care teams. This study aims to clarify the roles of medical social workers (MSWs) in such conferences. Semi-structured interviews were conducted with five MSWs working in tertiary emergency hospitals who had experience participating in discharge conferences. Analysis revealed three major roles of MSWs: first, sharing patient information and assessing post-discharge living arrangements to reduce information gaps between the hospital and home care teams; second, facilitating conferences by reframing medical issues into daily living concerns and creating an environment where patients and families can express their views; and third, providing follow-up and continuous support after discharge, assisting patients, families, and home care teams, while feeding back insights to hospital staff to strengthen collaboration. These findings suggest that MSWs are indispensable in acute care hospitals, contributing to seamless hospital-to-home transitions and supporting safe and sustainable home-based living for older adults.