For example, a medical provider may report that a frail elderly patient, who lives alone, is medically stable for discharge and plans to discharge the patient home with in-home services. After assessing the patient's psychosocial needs, the medical social worker determines that the patient does not have the ability to manage at home safely even with the intervention of a home care worker. The medical social worker informs the medical provider that the proposed discharge plan may place the patient at risk and the discharge plan is deferred pending further assessment. The medical social worker can then collaborate with multidisciplinary providers to develop a more appropriate discharge plan even if that leads to discharge delays.