When Social Workers Drop the Ball and Nurses Clean It Up

The nurse walks in. She’s here for a wound check, maybe a medication review. But before she even opens her bag, the patient’s daughter pulls her aside. She’s crying. She’s overwhelmed. She says no one ever called her back about supplies. The social worker promised to help, but nothing happened. Now she’s looking at the nurse like, “Can you fix this?”

And most of the time, the nurse does.

Home health nurses aren’t just there for blood pressure and bandages. They’re the ones who see what’s actually happening inside the home. They know when there’s no food in the fridge. They notice when the bills are piling up. They hear the quiet panic in a caregiver’s voice. When the social worker forgets, drops the ball, or disappears altogether, it’s usually the nurse who steps in.

That’s not how it’s supposed to work.

Social workers in home health and hospice are supposed to be the safety net. They help with insurance issues, locate community support, find resources for transportation or caregiving. They’re trained to handle the hard conversations about money, stress, advance directives, and long-term planning. But too often, they’re overloaded or spread too thin. Some agencies don’t have enough of them. Others don’t prioritize follow-up.

The result? Families are left waiting. The nurse shows up, ready to provide care, and walks straight into an emotional fire. There’s no supplies. No call back. No clarity. And even though it’s not her job, she tries to fix it because she’s the only one who’s there.

This gets even messier when the agency isn’t using good communication tools. If there’s no system to track which referrals were made, or whether a call happened, nothing gets followed up on. Notes are lost. Messages get passed around, but no one takes ownership. Agencies that rely on verbal updates or paper logs are the ones where social workers vanish and nurses burn out trying to cover the gaps.

Agencies using home care software can prevent a lot of this. With Alora, tasks, referrals, and communication logs are visible to the whole team. When a nurse enters a note about a family needing help with Medicaid paperwork, that task doesn’t disappear. It’s logged. It shows up in the workflow. The social worker sees it. The office sees it. That way, if it’s not done, there’s a record and someone can follow up.

The family doesn’t care who was supposed to handle it. They just want help. They want the bed rail that was promised. The transportation that was supposed to be arranged. The pharmacy mix-up fixed. When no one delivers, they look at the nurse, the only person who shows up consistently and expect her to do it all.

And she tries. Because she cares. But the system shouldn’t force her to do two jobs. It should support her so she can focus on clinical care, not spend her visit chasing down a missing walker or explaining insurance benefits.

When it works the way it should, everyone plays their part. The nurse notices a concern. The social worker follows through. The office tracks it. The family gets what they need. And no one has to carry more than their share.

If you’ve ever felt like you’re stuck waiting for a call that never comes, or if the nurse keeps stepping in to fix things outside her role, it’s a systems problem. Agencies that care about accountability use tools that make it easier to follow through. And they talk openly about it. If you’re not sure how your agency handles communication, ask. If they’re vague or defensive, that tells you a lot.