Here is the scenario:

You are a hospital social worker and Mr. and Mrs. Calhoun, an older Caucasian couple, came to your attention after Mrs. Calhoun had been hospitalized for dehydration. She was brought to the hospital based on the recommendation of her primary care physician who had found her to be quite confused and delirious during her visit to the doctor’s office. Mrs. Calhoun had been stable for the past few days, but her age (73) and her confusion had flagged her as an at-risk patient who would need additional attention to develop a discharge plan. The Calhouns live in their own home and their only son lives about 20 minutes away and helps out fairly regularly. The Calhoun’s live modestly on their pension and social security. Mr. Calhoun indicated that he wanted his wife discharged to their home because he was quite capable of looking after her.  Mr. Calhoun himself did not appear to have any observable limitations in his ability to carry out activities of daily living, although he did look tired. The Calhouns son stated he can only check in on the weekends. You are not entirely convinced of Mr. Calhoun’s ability to adequately care for his wife– she did after all have to be hospitalized for dehydration. According to the patient’s chart, Mrs. Calhoun’s confusion still seemed to persist, although she seemed okay when you spoke to her. The physician and the nursing staff want you to develop a discharge plan fairly quickly. What does your discharge plan include? Do you send Mrs. Calhoun home with in-home services? Do you send her for long-term care? Do you recommend follow up? What services (if any) do you recommend for Mr. Calhoun and/or their son?