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Social work care model

The social worker's intervention at FREMAP responds to a care model based on a methodology that allows for the assessment of social needs, the establishment of intervention objectives, and continuous support for the worker and their family.

Case detection and access

This phase involves identifying situations of vulnerability that require social intervention, originating from:

  • Referral from the health area.
  • Referral to nursing, psychology or physiotherapy.
  • Referral from the benefits area.
  • Direct detection by the social worker during ward visits, consultations, or visits to other hospitals
  • Direct request from the worker or family.
  • Company notice regarding a complex employment situation.

Target: Confirm if there are social, economic, family, or emotional needs that require intervention.

Based on the assessment, the social worker defines:

Priority needs

  • Emotional:
  • social;
  • economic;
  • labor.

Short and medium term intervention objectives.

Internal and external resources that will be activated.

Specific actions

Document management, technical assistance, mediation, benefits guidance, discharge preparation, family support measures, etc.

The plan is flexible, as it can be adapted to the clinical and social evolution of the worker. 

It is the central phase of social work at FREMAP. Includes:

Emotional support and containment

Support in critical moments, hospitalizations, job insecurity or serious consequences.

Orientation and resource management

Access to benefits: IT, IP, LES, dependency, disability, technical aids, public services, Special Benefits Commission, etc.

Intervention with the family

  • Care organization.
  • Training for adapting to home life after injuries.
  • Support in situations of family overload.

Interdisciplinary coordination

Meetings, consultations and ongoing communication with:

  • Clinical and hospital medicine.
  • Nursing.
  • Rehabilitation.
  • Psychology.
  • Financial benefits.

  • Review of objectives.
  • Detection of new needs.
  • Adjusting interventions to clinical evolution.
  • Situation reports for the care team or for companies.
  • Managing emerging situations (economic, family or work problems).

This phase is key in cases of long duration, serious consequences or social vulnerability.

Before discharge or a major change in the care process, the social worker ensures:

1

That the worker has the necessary support at home.

2

That has adequate technical assistance.

3

That the family is informed and trained.

4

That pending procedures have been processed (dependency, disability, IP…).

5

That there are no social barriers that hinder discharge or reintegration into the workforce.

6

Before discharge or a major change in the care process, the social worker ensures:

The intervention concludes when:

  • The objectives of the intervention plan have been achieved.
  • Social needs have been resolved or diverted.
  • The worker is discharged from medical or administrative care.

The social worker records:

  • Care notes.
  • Final assessment.
  • Social reports if necessary.

The intervention can be reactivated for a new phase if, after discharge:

  • a new social need arises;
  • an adaptation problem arises;
  • A difficulty arises with the company;
  • or the worker initiates a new benefits process.