Addressing social determinants of health (SDoH) is becoming increasingly important due to new regulations from the Centers for Medicare & Medicaid Services (CMS) and the shift toward value-based care payment models. With ongoing staffing shortages and a growing demand for home-based care services, social workers are taking on greater responsibilities to support the health care system.

In its final home health payment rule for 2025, CMS introduced four new items and modified one existing item related to SDoH in the Outcome and Assessment Information Set (OASIS) assessment framework. These changes will occur in the 2027 Home Health Quality Reporting Program (HHQRP).

Individuals requiring home health care often need complex support that addresses both their medical and psychosocial needs, especially if they are isolated from typical social interactions and services. Some home care teams are now integrating home health social workers (HHCSWs) to provide a comprehensive approach to care that considers these SDoHs.

“Social workers are essential to the services provided by CenterWell Home Health,” CCO at CenterWell Home Health, Sherri Rains told Home Health Care News. “They offer holistic emotional, mental and physical support to patients and families, addressing social determinants of health to enhance the care team’s efforts.”

CenterWell Home Health delivers skilled care, education and tools to individuals managing chronic conditions across 37 states, with more than 350 locations.

“CenterWell’s social workers collaborate with our physicians, nurse practitioners and other clinicians to tackle all the challenges faced by home health patients,” Rains added. “They are integral to the interdisciplinary communication process through advocacy, relationship-building, teamwork and trust.”

HHCSWs help patients navigate the health care system and access necessary resources while remaining at home to manage their health and well-being. Their support includes managing illness-related emotional challenges, coordinating community services and advising family caregivers.

“Social workers often serve as the bridge between medical professionals and the realities of a client’s social circumstances,” said Catherine Briggs, care integration manager at Bayada Home Health and Hospice, told HHCN. “Our assessments can pinpoint areas of struggle and advocate for improved support. Within the home health care team, the social worker concentrates on current obstacles and assists clients in creating a plan for their future. Addressing needs such as lack of medical transportation, food insecurity or limited access to affordable health services and medications can make the difference between successful home recovery and hospital readmission.”

Bayada provides home health, home care and hospice services in 23 states, as well as in Canada, Germany, India, Ireland, New Zealand, South Korea and the U.K.

To fully support patients, care must go beyond attention to physical symptoms, according to Rachel Witt, chief clinical officer for Aveanna Healthcare (Nasdaq: AVAH).

“Understanding and addressing the psychosocial needs of home health care patients is crucial for achieving positive outcomes,” Witt told HHCN. “Medical social workers play a key role in the home health care team by providing education, resources and support to assist patients and their families in coping with conditions, diseases or injuries.”

Aveanna Healthcare, based in Atlanta, offers pediatric and adult health services, including nursing, rehabilitation, therapy, day treatment centers and home health and hospice services.

Social workers also can help patients adjust to the ways their life will change following a serious illness diagnosis.

“Including social workers is vital when addressing psychosocial needs,” Barbara Andazola, vice president of clinical practice, strategy, and programs for home health at Amedysis told HHCN. “Patients often find it difficult to adjust to lifestyle changes brought on by a new or worsening diagnosis, which can adversely affect their physical health. A patient’s emotional and psychosocial well-being greatly influences how they handle their illness and make health-related decisions.”

Amedisys (Nasdaq: AMED), headquartered in Baton Rouge, Louisiana, provides home health care, hospice, palliative care and high-acuity care services in 38 states.

Andazola explained that including HHCSWs in a patient’s care plan to counsel and address SDoH can greatly influence clinical outcomes. According to the National Association of Social Workers (NASW), HHCSWs work closely with the health care team to ensure that the needs of individuals and their families are met and the care plan is effectively followed.

“Social workers must be part of the health care team,” Mirean Coleman, Senior Practice Associate for Clinical Social Work at NASW in Washington, D.C. said “They ensure that caregivers and patients receive the support and resources necessary to achieve the best possible care.”

Briggs offered the example of Bayada’s Care Integration program to empower home health clinicians in identifying high-risk patients and providing education regarding additional in-home care that supports the client’s changing needs. Care Integration aims to help clients find the right level of care at the right time, she explained.

“Our Care Integration managers work closely with the home health teams to identify clients at high risk for rehospitalization and [those who] may require a higher level of care,” Briggs said. “They then partner with the home health team to educate clients and families on the hospice benefit and ensure a seamless transition between Bayada service lines. Care Integration managers meet clients and families where they are, emotionally, and ensure they can remain in their homes with comfort, dignity and respect.”

HHCSWs provide a holistic review of the client’s physical, emotional, social and spiritual needs and what areas of assistance will enhance their ability to care for themselves in the community. This is done by listening to client needs, providing education and resources and advocating for the client and family.

“With this process, challenges arise that can impact both the HHCSW and the client’s goals for care,” Susan Owens, a medical social worker at Elara Caring, told HHCN. “One of these challenges includes lack of or limited funding for programs that hinder a patient’s access to services that could ideally meet their needs. Age and income restrictions, state or federal budget constraints, or cutbacks create these limits. In a values-based care system, in which quality is emphasized over quantity, the role of the HHCSW will be of continued importance in providing the support, advocacy and linkage to resources that will enhance satisfaction and foster safety and sufficiency in the community.”

Dallas-based Elara Caring is a home-based care provider with about 200 locations across 17 states. The company serves more than 60,000 patients.

A family resource 

HHCSWs provide essential support and assistance to patients and their families during their most vulnerable times. They offer counseling services to help individuals cope with various diagnoses, including acute, chronic or terminal illnesses. Additionally, social workers provide caregiver support through education and connections to resource groups.

One of their key roles is educating patients and families about medical conditions, treatment options, advance care planning and available community resources. By empowering patients to make informed decisions, HHCSWs help them navigate the health care system and access supportive services that enhance their quality of life. They also facilitate discussions about end-of-life care preferences, advance directives and hospice care, ensuring patients’ wishes are honored and respected.

Additionally, HHCSWs advocate for patients and their families, ensuring their voices are heard, their preferences respected, and their rights upheld. They also collaborate with other interdisciplinary care team members to coordinate services, address barriers to care and facilitate smooth transitions between health care settings.

“Social workers understand the health care environment and the options available for patients and families,” Witt said. “Incorporating a social worker early in the process is an important step toward setting goals and creating a holistic care plan for the patient. Unfortunately, in many cases, a social worker is not involved until a crisis occurs. Engaging a social worker early can help mitigate issues and prevent a crisis from arising.”

With their extensive knowledge of community resources, support services and financial aid programs, HHCSWs assist patients in connecting with resources for housing assistance, transportation, home-delivered meals, caregiver support, financial aid and other social services that address practical needs and promote independence. They work alongside community agencies, nonprofit organizations and government bodies to ensure patients receive comprehensive, coordinated care that addresses their social and environmental needs.

Andazola provided an example of a typical situation where social workers assist patients in accessing financial resources for necessary prescription medications.

“If a patient cannot afford to buy medications, they may skip doses or cut them in half, which can lead to hospitalizations,” she explained. “By addressing these financial challenges, social workers promote patient engagement in self-care, improve medication management and help reduce avoidable hospitalizations.”

Filling the gap

Around 21,350 social workers are employed in the home health care services industry, according to the Bureau of Labor Statistics. While this number represents a significant portion of HHCSWs in the U.S., Coleman believes the industry needs more.

“I think there is an employment gap,” she said. “There should be a social worker on every team. Social workers should be involved in the assessment and treatment processes from the moment the physician formulates a care plan—from the initial visit to the time the patient is discharged from the medical facility to home care.”

Andazola notes that recruiting and retaining social workers can be difficult due to coverage limitations under the Medicare home health benefit and certain private payers. Consequently, social work services are frequently offered on a short-term basis, complicating efforts to establish a caseload that justifies full-time employment with benefits.

“There is a gap in the number of social workers in home care to meet the growing demand,” Margot Lambright, division director of psychosocial support at Bayada Hospice, said. “The need for social workers in home care has been increasing due to the aging population and risk in chronic health conditions. Many agencies face challenges in hiring and retaining social workers due to a shortage of workers, financial constraints, and in some cases, a lack of awareness about the influence and opportunities for social workers in home care.”

Like other health care roles, HHCSWs can work in various environments, such as hospitals and clinics, which generally provide higher salaries. This competition makes the home health care field less attractive. Furthermore, rigorous degree requirements and challenging caseloads may discourage individuals from pursuing home health social work.

“Most home health agencies require social workers to hold a master’s degree in social work, which limits the pool of available candidates,” Witt explained. “Many social workers manage large caseloads due to these degree requirements. Each patient presents unique family dynamics and community resource needs, which can easily lead to job fatigue and burnout. Depending on the agency’s location and service territory, a social worker may have to cover a large geographic area, necessitating regular travel that many find unappealing.”

The average pay for HHCSWs in the U.S. is about $37 per hour, which translates to an annual salary of roughly $77,970, with variations depending on location and experience level, based on recent data from Indeed. Top earners can make around $110,000 annually, but agencies often need to offer more than just competitive compensation to attract qualified applicants due to the factors mentioned by Witt.

“Certainly, recruitment and retention of social workers are challenging,” Rains said. “Probably the biggest issue is the availability of this workforce. We often find that social workers work multiple jobs per diem—essentially, as needed, part-time. While we don’t require social workers in every case, they are critical to better outcomes when their expertise is needed.”

Home health agencies can attract social workers by highlighting the unique aspects of their roles, emphasizing a strong collaborative culture with other health care professionals, offering competitive benefits, actively engaging with social work organizations and schools, and sharing success stories that demonstrate the positive impact of their services, according to NASW.

However, agencies must ensure job postings clearly outline the responsibilities and qualifications required. The NASW suggests that agencies foster a collaborative environment and offer opportunities for continuing education, training and mentorship programs to support HHCSWs’ growth. They should also highlight any specialization in patient populations or unique services provided, as these factors can attract social workers looking to concentrate on a specific practice area.